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[Your Clinic Name Here] Patient Satisfaction Survey
We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.
Your Age:
Your Sex:
Your Race/Ethnicity: Asian
Pacific Islander
Black/African American
Native
Male
____ American Indian/Alaska
White (Not
Hispanic or Latino)
Female Hispanic or Latino (All
Races)
Please circle how well you think we are doing in the following areas:  GREAT 5  GOOD 4  OK 3  FAIR 2  POOR 1 
Ease of getting care:  
Ability to get in to be seen  5  4  3  2  1 
Hours Center is open  5  4  3  2  1 
Convenience of Center’s location  5  4  3  2  1 
Prompt return on calls  5  4  3  2  1 
Waiting:  
Time in waiting room  5  4  3  2  1 
Time in exam room  5  4  3  2  1  
Waiting for tests to be performed  5  4  3  2  1  
Waiting for test results  5  4  3  2  1  
Staff:  
Provider: (Physician, Dentist, Physician Assistant, Nurse Practitioner)  
Listens to you  5  4  3  2  1  
Takes enough time with you  5  4  3  2  1  
Explains what you want to know  5  4  3  2  1  
Gives you good advice and treatment  5  4  3  2  1  
Nurses and Medical Assistants:  
Friendly and helpful to you  5  4  3  2  1  
Answers your questions  5  4  3  2  1  
Please circle how well you think we are doing in the following areas:  GREA T 5  GOO D 4  OK 3  FAIR 2  POO R 1  
All Others:  
Friendly and helpful to you  5  4  3  2  1  
Answers your questions  5  4  3  2  1  
Payment :  
What you pay  5  4  3  2  1  
Explanation of charges  5  4  3  2  1  
Collection of payment/money  5  4  3  2  1  
Facility:  
Neat and clean building  5  4  3  2  1  
Ease of finding where to go  5  4  3  2  1  
Comfort and Safety while waiting  5  4  3  2  1  
Privacy  5  4  3  2  1 
Confidentiality:  
Keeping my personal information private  5  4  3  2  1 
The likelihood of referring your friends and relatives to us:  5  4  3  2  1 
Do you consider this center your regular source of care? Yes No 
What do you like best about our center?
________________________________________________
____________________________________________________________________________
__
____________________________________________________________________________
__
What do you like least about our Center?
__________________________________________
____________________________________________________________________________
__
____________________________________________________________________________
__
Suggestions for improvement?
___________________________________________________
____________________________________________________________________________
__
____________________________________________________________________________
__
Thank you for completing our Survey!
SECTION 2
GUIDELINES
For Administering the Patient Satisfaction Survey
How to Give the Survey to Patients
To ensure consistency in the administration of the Patient Satisfaction Survey, it is suggested that the Survey be given to patients in one of three ways listed below.
A stack of the Survey's is made readily available to patients at the time they check out from the health center. If the Survey's are administered this way, have an envelope or box, marked "Completed Patient Satisfaction Survey's," right next to the stack of Survey's for patients to put their completed Survey into.
Someone on staff hands the Survey to a patient at the end of their visit, and asks them to complete it prior to leaving the health center. After the patient has completed the Survey, immediately place the Survey in an envelope and do not read any of the patient's responses to the Survey, or show the patient where there is a centrally located
envelope or box, marked “Completed Patient Satisfaction Survey’s,” to place the Survey in.
For patients that may have difficulty reading, someone who is not a health care provider at your health center, should assist them. If appropriate, health center staff should ask the patient if they need help to complete the Survey. Individuals that can assist patients in reading the Survey can include outreach workers, nonhealth care provider staff, family members, patient's friends, and volunteers. After the patient has completed the Survey, immediately place the Survey in an envelope and do not read any of the patient's responses to the Survey, or show the patient where there is a centrally located envelope or box,
marked “Completed Patient Satisfaction Survey’s,” to place the Survey
in.
When the Survey is given to patients, be sure to tell them that they are helping you improve the quality of your services and that all of their responses to the Survey will be kept confidential/anonymous.
Cost Estimate of Administering the Patient Satisfaction Survey
To help better understand the costs associated with administering the Patient Satisfaction Survey, you can estimate your total costs as well as those costs associated with preparing to administer the Survey. This cost estimate should include both direct costs, such as cost for duplicating the Survey itself, and administrative costs, specifically the costs associated with staff time.
FTE Types Involved  # of FTE's  # of Hours (Estimated)  Total Cost (# hours x Salary) 
 
 
Midwives  
 
 
 
 

SECTION 3
SAMPLE SIZE CALCULATION
Definitions and Terms
Population
The entire group of objects or people about which information is wanted is called the population.
Sample
A sample is a part of the population that is actually examined in order to gather information.
Representative Sample
A sample is representative of the population from which it is taken if the characteristics of the sample mimic those of the population.
Confidence Interval
A range of values of a sample statistic that is likely (at a given level of probability, called a confidence level) to contain a population parameter. The interval that will include the population parameter a certain percentage (confidence level) of the time. The wider the confidence interval, the higher the confidence level.
Confidence Level
A desired percentage of the scores (usually 95% or 99%) that would fall within a certain range of confidence limits.
Confidence Limits
The upper and lower values of a confidence interval, that is, the values defining the range of a confidence interval.
EXAMPLE: From the general population 1,000 people covering the voting age range were polled on the senatorial race. The poll predicted that, if the election were held today, the Republican candidate for Senator would win 60% of the vote. This
prediction could be qualified by saying that the pollster was 95% certain (confidence level) that the prediction was accurate plus or minus 3% (confidence interval). This means the Republican candidate has a 95% chance of winning between 57% and 63% (confidence limits) of the vote.
Types of Samples
Subjective or Convenience Sample
Has some possibility of bias
Cannot usually say it is representative
Selection made by ease of collection
Types of Samples  continued
Simple Random Sample
No subjective bias
Equal chance of selection; e.g., select the fifth chart seen on every third day
Can usually be backed to say it is representative
Systematic Sample
Is a random sample
Equal chance of selection due to methodology; e.g., computergenerated list of random numbers, or every fifth name on a generated list
Can usually be backed to say it is representative
Stratified Sample
Breakdown the population into subgroups, then take a random sample from each subset
Can usually be backed to say it is representative
Sample Size Calculation
Automated method  Follow this link to an electronic calculator to automatically calculate sample size. You need to know your population size and desired confidence level: http://www.macorr.com/ss_calculator.htm.
Manual Calculation:
You must have:
Population Value: Size of the population from which the sample will be selected. (Number of users or number of encounters)
Expected Frequency of the Factor under Study always err toward 50%
Worst Acceptable Frequency If 50% is the true rate in the population, what is the result farthest from the rate that you would accept in your sample? If your confidence interval were 4%, then your worst acceptable frequency would be 54% or 46%.
Formula: Sample Size = n / [1 + (n/population)] In which n = Z * Z [P (1P)/(D*D)]
P = True proportion of factor in the population, or the expected frequency value D = Maximum difference between the sample mean and the population mean,
Or Expected Frequency Value minus () Worst Acceptable Value
Z = Area under normal curve corresponding to the desired confidence level
III. Sample Size Calculation  continued
Confidence Level
Value for Z
90%
1.645
95%
1.960
99%
2.575
99.9%
3.29
Population Survey Characteristics
The sample to be taken must be a simple random or otherwise representative sample. A systematic sample, such as every fifth person on a list, is acceptable if the sample is representative. Choosing every other person from a list of couples would not give a representative sample, since it might select only males or only females.
The question being asked must have a "yes/no" or other twochoice answer, leading to a proportion of the population (the "yes's") as the final result.
Examples
Trait or Factor Prevalence
Suppose that you wish to investigate whether or not the true prevalence of HIV antibody in a population is 10%. You plan to take a random or systematic sample of the population to estimate the prevalence. You would like 95% confidence that the true proportion in the entire population will fall within the
confidence interval calculated from your sample.
Let’s say that the population size is 5000, the estimate of the prevalence of 10%, and either 6% or 14% as the “worst acceptable” value, which is the end point of your confidence interval. (Please note: the high and low values are calculated by adding and subtracting your confidence interval, in this case “4", to your estimate of the prevalence.)
Population Value = 5000
Expected Frequency of the Factor under Study = 10% Worst Acceptable Frequency = 14% or 6%
32)
P = Expected Frequency Value = 10%
D = (Expected Frequency  Worst Acceptable) = 14%10%=4%, OR 10% 6%=4%
Z = 1.960 with Confidence Level of 95% (See Confidence Level values, page
III. Sample Size Calculation – continued
Formula: Sample Size = n / [1 + (n/population)] In which n = Z * Z [P (1P)/(D*D)]
First, calculate the value for “n”.
N = Z * Z [P (1P)/(D*D)]
N = 1.960 * 1.960 [0.10(1  0.10) / (0.04 * 0.04)
N = 1.960 * 1.960 [0.10(0.90) / (0.0016)
N = 1.960 * 1.960 [.09 / .0016]
N = 1.960 * 1.960 [56.25]
N = 1.960 * 110.25
N = 216.09
Next, Calculate the Sample Size. (S = Sample Size)
S = n / [1 + (n / population)
S = 216.09 / [1 + (216.09 / 5000)]
S = 216.09 / [1 +. 043218]
S = 216.09 / 1.043218
S = 207
Clinical Performance Rates
Suppose you want to evaluate the compliance of your center with standard Quality Assurance procedures or with the Clinical Measures. You plan a random or systematic sample of the center's charts, and seek a 95% confidence level that the sample is representative of all the center's charts and that the compliance rate will fall within the confidence interval you desire. As this is a measure of how personnel perform a task, you would expect a high rate of compliance in completing a required task. Thus, it is strongly suggested that you use 95% (no lower than 90%) as your Expected Frequency, as 99.9% perfection is not a reasonable expectation. Performance is expected of all trained personnel and should not fall below a reasonable level. This level is suggested as 85% (no lower than 80%) for the “Worst Acceptable" value. The population size will equal the
population of the life cycle or subset: in this example we will use 800. It is strongly suggested that you use the 95% Confidence Level for the Z Value.
Population Value = 800
Expected Frequency of the Factor under Study =95% Worst Acceptable Frequency = 85%
III. Sample Size Calculation  continued
P = Expected Frequency Value = 95%
D = (Expected Frequency  Worst Acceptable) = 95% 85% = 10%
Z = 1.960 with a Confidence Level of 95% (See Confidence Level Values, page 32)
Formula: Sample Size = n / [1 + (n/population)] In which n = Z * Z [P (1P)/(D*D)]
First, calculate the value for “n”. N = Z * Z [P (1P)/(D*D)]
N = 1.960 * 1.960 [0.95(1  0.95) / (0.10 * 0.10)
N = 1.960 * 1.960 [0.95(0.05) / (0.01)
N = 1.960 * 1.960 [.0475 / .01]
N = 1.960 * 1.960 [4.75]
N = 1.960 * 9.31
N = 18.24
Next, Calculate the Sample Size. (S = Sample Size)
S = n / [1 + (n / population)
S = 18.24 / [1 + (18.24 / 800)]
S = 18.24 / [1 + 0.0228]
S = 18.24 / 1.0228
S = 17.8, or 18
NOTE: If the calculated sample size is lower than 25 at a 95% confidence level, the Clinical Measures require you to use a minimum of 25 surveys annually.
The requirement of 25 minimum can be explained by the concept of Margin of Error. This is calculated by taking the square root of the sample size and dividing it into 1, then multiplying by 100%. A graph would show that a sample size of 25 gives a Margin of Error at 20%.
Actually, by this method the most practical sample size is 40, giving a Margin of Error at 15%. Over 40, the improvement in the error is very small.
SECTION 4
DATA COLLECTION, ANALYSIS AND REPORTING
DATA COLLECTION AND ANALYSIS
COLLECTING DATA:
To put your data into a useable format simply use a matrix built in a spreadsheet format (Excel or Lotus 123 will work fine) such as the sample below, and put the total number of answers for the time period you are using to measure the sample (e.g. 1month, 3 months, 6 months, etc.) in each cell.
Patient Satisfaction Survey Sample Data Collection Sheet
Question
Great
Good
OK
Fair
Poor
No
Response
EASE OF GETTING CARE
Ability to Get in to be seen
40
44
16
0
0
0
Hours Center is Open
56
36
4
4
0
0
Convenience of Center’s
location
48
44
4
0
4
0
Prompt return on calls
60
36
4
0
0
0
WAITING
Time in Waiting Room
56
36
8
0
0
0
Time in Exam Room
56
44
0
0
0
0
Waiting for tests to be
performed
40
56
4
0
0
0
Waiting for test results
40
56
4
0
0
0
STAFF  PROVIDER
Listens to you
84
16
0
0
0
0
Takes enough time with you
80
20
0
0
0
0
Explains what you want to
know
76
24
0
0
0
0
Gives you good advice and
treatment
80
20
0
0
0
0
STAFF  NURSES AND MEDICAL ASSISTANTS
Friendly and helpful to you
84
16
0
0
0
0
Answers your questions
84
16
0
0
0
0
STAFF  ALL OTHERS
Friendly and helpful to you
72
28
0
0
0
0
Answers your questions
72
28
0
0
0
0
PAYMENT
What you pay is reasonable
48
44
8
0
0
0
Explanation of charges
48
44
8
0
0
0
Collection of payment / money
48
44
4
0
0
4
FACILITY
Neat and clean building
64
28
4
0
4
0
Ease of finding where to go
72
28
0
0
0
0
Comfort and safety while
waiting
72
28
0
0
0
0
Privacy
60
36
0
0
0
4
CONFIDENTIALITY
Keeping my personal
information private
72
28
0
0
0
0
THE LIKELIHOOD OF REFERRING YOUR FRIENDS AND RELATIVES
TO US.
72
20
0
0
0
8
DO YOU CONSIDER THIS CENTER
YOUR REGULAR SOURCE OF CARE?
Yes  91
No  2
No Response  7
ANALYSING DATA
Data analysis is in a simple descriptive format. Divide the number in each cell in the spreadsheet by the total number of patients doing the survey.
In the example above, the sample size was 100 patients. Each number was divided by 100 to get the percent (%) of patients in each category. See the Patient Satisfaction Survey Sample Report that follows, to develop your final report.
DATA REPORTING
Patient Satisfaction Survey Sample Report
Question  Great  Good  OK  Fair  Poor  No Response 
EASE OF GETTING CARE  
Ability to Get in to be seen  40%  44%  16%  0%  0%  0% 
Hours Center is Open  56%  36%  4%  4%  0%  0% 
Convenience of Center’s location  48%  44%  4%  0%  4%  0% 
Prompt return on calls  60%  36%  4%  0%  0%  0% 
WAITING  
Time in Waiting Room  56%  36%  8%  0%  0%  0% 
Time in Exam Room  56%  44%  0%  0%  0%  0% 
Waiting for tests to be performed  40%  56%  4%  0%  0%  0% 
Waiting for test results  40%  56%  4%  0%  0%  0% 
STAFF  PROVIDER  
Listens to you  84%  16%  0%  0%  0%  0% 
Takes enough time with you  80%  20%  0%  0%  0%  0% 
Explains what you want to know  76%  24%  0%  0%  0%  0% 
Gives you good advice and treatment  80%  20%  0%  0%  0%  0% 
STAFF  NURSES AND MEDICAL ASSISTANTS  
Friendly and helpful to you  84%  16%  0%  0%  0%  0% 
Answers your questions  84%  16%  0%  0%  0%  0% 
STAFF  ALL OTHERS  
Friendly and helpful to you  72%  28%  0%  0%  0%  0% 
Answers your questions  72%  28%  0%  0%  0%  0% 
PAYMENT  
What you pay is reasonable  48%  44%  8%  0%  0%  0% 
Explanation of charges  48%  44%  8%  0%  0%  0% 
Collection of payment / money  48%  44%  4%  0%  0%  4% 
FACILITY  
Neat and clean building  64%  28%  4%  0%  4%  0% 
Ease of finding where to go  72%  28%  0%  0%  0%  0% 
Comfort and safety while waiting  72%  28%  0%  0%  0%  0% 
Privacy  60%  36%  0%  0%  0%  4% 
CONFIDENTIALITY  
Keeping my personal information private  72%  28%  0%  0%  0%  0% 
THE LIKELIHOOD OF REFERRING YOUR FRIENDS AND RELATIVES TO US.  72%  20%  0%  0%  0%  8% 
DO YOU CONSIDER THIS CENTER YOUR REGULAR SOURCE OF CARE?  Yes – 91%  No  2%  No Response – 7% 
Age  Ranged from 5  61
Sex   76%  Female 
24%  Male  
Race  92%  White 4%  Unknown 
4%  No Response 
What Do You Like Best About Our Center
Friendliness of everyone. (2)
Everyone is very, very nice and pleasant. Everyone seems to like their job and it reflects in their mood, which seems happy.
The personal interest shown.
Great with children and in what they do.
The staff and the concern they show for everyone. How nice everyone is here. (2)
The people and the location. Staff is great. (6)
All around great.
Great people with wonderful personalities. Friendly staff  great with kids.
Prices
Treatment I have received has been done in a professional and very pleasant way. Atmosphere is good.
Doctor and receptionist. TV
Everything (2)
What Do You Like Least About Our Center
Hate going to the dentist but everyone made it easy. Wish they could do all dental procedures.
Location. (3) Not too clean.
Hours could be longer (after 4:30) Bathroom not handicap accessible. Takes a long time for appointments.
Suggestions for Improvement
In the Medical area (it sometimes is like a circus; the nurse and sometimes doctors are laughing and joking) that is not professional. Also the secretaries are the same way. I also think when you have tests done, they should let you know promptly instead of letting a week or so go by and then you have to call them.
Call to remind me of appointment. I forget them easy. We love you just the way you are.
It is great  leave as is now. Single nurses.
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