Appendix A
PATIENT SATISFACTION FORMS & STEPS FOR ITS IMPLEMENTATION
OPD patient Feedback
Dear Client,
You have spent your valuable time in the hospital in connection with your / relative’s/ friend’s
treatment. You are requested to share your opinion about the quality of services, which you
experienced, while visiting the hospital. The information provided by you would be kept confidential
and would only be used for improving the services.
Please tick the appropriate box and drop the questionnaire in the Suggestion box
Sl No Attributes Poor Fair Good Very Excellent No comments
1 2 3 Good 5
4
1 Availability of sufficient information in Hospital (Directional
& location signages, Registration counter, Laboratory,
Radiology Department, Dispensary, etc)
2 Waiting time at the registration counter more than 30 10-30 mins 5-10 mins Within 5 mins Immediate
mins
3 Behaviour and attitude of Hospital Staff
4 Amenities in waiting area (chairs, fans, drinking water and
cleanliness of bathrooms & toilets)
5 Attitude & communication of Doctors
6 Time spent on consulting, examination and counselling
7 Availability of Lab and radiology investigation facilities within
the hospital
8 Promptness at Medicine distribution counter
9 Availability of prescribed drugs at the hospital dispensary
10 Your overall satisfaction during the visit to the hospital
1. What improvement would you like to see in the hospital
2. What made you come to this hospital for treatment?
3. Would you like to return to this hospital next time for treatment
4. Your valuable suggestions
Date ____________ Clinic________ Age _____________Sex_______
Inpatient Feedback
Dear Client
You have spent your valuable time in the hospital in connection with your / relative’s/ friend’s
treatment. You are requested to share your opinion about the quality of services, which you
experienced, while staying in the hospital. The information provided by you would be kept confidential,
and would only be used for improving the services.
Please tick the appropriate box and drop the questionnaire in the Suggestion box
Sl No Attributes Poor Fair Good Very Excell No
1 2 3 Good ent comments
4 5
1. Availability of sufficient information at
Registration/Admission counter (Directional & location
signages, Registration counter, Laboratory, Radiology
Department, Dispensary, etc)
2. Waiting time at the Registration/Admission counter more than 30 10-30 mins 5-10 mins Within 5 mins Immedia
mins te
3. Behaviour and attitude of hospital staff at the registration/
admission counter
4. Your feedback on discharge process
5. Cleanliness of the ward
6. Cleanliness of Bathrooms & toilets
7. Cleanliness of Bed sheets, pillow-covers, etc
8. Cleanliness of surroundings and campus drains
9. Regularity of Doctor’s attention
10. Attitude & communication of Doctors
11. Time spent for examination of patient and counselling
12. Promptness in response by Nurses in the ward
13. Round the clock availability of Nurses in the ward
14. Attitude and communication of Nurses
15. Availability, attitude & promptness of Ward boys/girls
16. All prescribed drugs were made available from Hospital
Supply
17. Your Perception of Doctor’s knowledge
18. Diagnostics Services were provided within the hospital
19. Timeliness of supply of the diet and its quality
20. Your overall satisfaction during the treatment as an in-
patient
1. What improvement would you like to see in the hospital
2. What made you come to this hospital for treatment?
3. Would you like to return to this hospital next time for treatment
4. Your valuable suggestions
Date __________ Ward_________ Age _____________Sex_______ Date of Admission
Methodology
Patient/Client satisfaction surveys are the integral part of Quality Improvement program at facility
level. It gives the valuable information about patient perception and experience about the quality
services, which of course will guide service providers to further improve the processes and service
delivery. Apart from taking patient feedback a Patient Satisfaction improvement program includes
analysing feedback given by patients, root cause analysis to identify the causes of low satisfaction,
preparing action plan and taking corrective actions to complete the continual improvement cycle
(Plan-Do-Check -Act). Following is a brief description of different steps for patient satisfaction
program.
1. Plan –
a. Periodicity- Plan for frequency of Patient Satisfaction Survey. Large secondary care
hospitals like districts hospitals can have survey on monthly basis. Smaller facilities like
PHC and CHC may take patient satisfaction on quarterly basis.
b. Stationary – Translate patient satisfaction survey in local language and ensure that
formats are available in adequate no. at OPD clinics/registration counter/May I Help you
desk and Nursing station in ward. The above-mentioned formats can be used for
conducting outpatients and In-patients satisfaction survey.
c. Responsibility- Designate who will be taking and collecting feedback. Hospital Manager /
Quality Manager may be responsibility to coordinate the program
d. Sample Size – For getting valid results sample size should be adequate. Following table
gives simple guidance how much should be the Sample size based on patient load in
previous quarter. It should not be less than 30 for being statically valid.
Populatio Sample Size (Number of patients to be surveyed)
n (OPD Margin of Margin of Margin of Margin of
Attendanc Error -10% Error -10% Error - 5% Error -5%
e/ IPD Confidence Confidence Confidence Confidence
Admission Level -90% Level -95% Level -90% Level -95%
s)
10 9 9 10 10
20 16 17 19 20
50 29 34 43 45
100 41 50 74 80
200 51 66 116 132
300 56 73 143 169
500 60 81 176 218
1000 64 88 214 278
3000 67 94 249 341
5000 67 95 257 257
10000 68 96 264 370
15000 68 96 266 375
20000 68 96 268 377
30000 68 96 269 380
50000 68 96 270 382
100000 68 96 270 383
2. Do-
Patient feedback should be taken as per decided plan and sample size. While taking
feedback it should be taken care of that all departments are equally covered specially the
services having high case load like ANC clinic, Maternity ward etc. Feedback should also
represent patient those can not give feedback by their own like illiterates, disabled and
children’s through affirmative measures like verbal feedback from illiterate patients and
feedback from parents for new-born and children. Exit feedback should be preferred from
who have already availed the services e.g. Like at Pharmacy counter for OPD and at the time
of discharge in IPD . Filled forms should be collected and submitted to coordinator.
3. Check – Feedback collected should be collated and analysed. Analysis should generate overall
as well as area/attribute wise score. Lowest performing two attributes should be identified and root
cause analysis should be done for them.
4. Act- Action plan should be prepared on causes identified during root cause analysis including
corrective and preventive action to be taken, time line and person responsible for taking action.
Compliance to action should be reviewed monthly.
Following illustration shows the process and steps of Patient Satisfaction Improvement Program –
