Appendix 3.2.2 Client Satisfaction Survey questionnaire secondary health facilities.pdf

Republic of Liberia Ministry of Health

P. O. BOX 10 – 9009

1000 MONROVIA 10, LIBERIA

WEST AFRICA

Hospital-level Client Satisfaction Survey (CSS) Questionnaire

County:

District:

Health Facility:

CBO:

1. Information on Hospital services

MRN (Master Registration No.

Patient Name/ Surname

County District Family/Household Representative, Contact information

Section B: To be Completed by the CBO community verification Agent Instructions: Please complete the questionnaire by circling the appropriate response and writing where required.

1. Consultation/Hospital Visit Date (Day-Month-year)

………/……. /20……

2. Do you know this person (within the household)?

(1) Yes (0) No

3. If you know the person, how old is the person? ..…………………. Years

4. Who within the household is confirming knowing the person

(1) The person him/herself

(2) Another person from the household

(3) The village/town Representative

(4) Neighbour

(5) Other (Specify)………………

5. Did the person visit the Hospital over the past 3 months?

(1) Yes (0) No

6. If yes, for what service did you visit the Hospital?

Questionnaire ID

Client Satisfaction Survey data collection Tool (December 2018)

7. Can you tell us when was the last time you visited this Hospital? (Estimation)

………/……. /20……

If the patient has been at the Hospital over the past quarter, continue with question on the next sections, if not stop here

2. Patient Perception

8. How were you satisfied with the service you received at the Hospital?

(0) Not satisfied at all

(1) Fairly Satisfied

(2) Very satisfied

(Please have the person indicate an explanation for their level of satisfaction here)

9. Did you go to another Hospital?

If no skip to question 12

(0) Yes

(1) No

(Write the reason for response given)

10. If yes, which other Hospital did you go to?

(0) Government Hospital

(1) Private Hospital

(2) Private Hospital

(3) Traditional Practitioners

(4) Other (Specify) _____________________________

11. Would you recommend the use of the health facility to relatives and friends?

(0) No

(1) Yes

Max Possible score=4

3. Patient Satisfactions

12. How much time did you wait before being attended to?

________________Hrs______________Minutes

13. How did you appreciate the waiting time? (0) Not Acceptable

(1) Acceptable

14. How did you find the services provided to you against your expectations ?

(1) Worse than expected

(2) Better than expected

(3) As expected

15. Did the nurse explain your condition or the service(s) provided?

(0) Yes

(1) No

16. If explanation was given, do you now understand your condition/services you came for?

(0) Not at all

(1) Very little

(2) To a great extent

17. Was the consultation done in confidentiality?

(0) No

18. In your opinion, do health workers at the Hospital have the ability to perform their work?

(0) Not at all

(1) Fair

(2) Very competent

19. Health workers are working 24 hours, all 7 days of the week?

(0) No

20. Are you satisfied with Hospital sanitation:

waiting area, ward condition, water, bathrooms?

(0) Not at all

(1) Fairly satisfied

(2) Very satisfied

21. Were you prescribed medicine during this visit?

(0) No

22. If yes, were the prescribed medicines available at the health facility?

(0) None available

(1) Some available

(2) All available

23. Did the health workers explain to you how to take medication?

24. Did you have to pay for any service at the Hospital? (If No skip to question 27)

(0) Yes

(1) No

25. If yes, for which service did you pay for?

Specify the currency

(0) Registration fee LD……………… or US$

(1) Consultation LD……………… or US$

(2) Medication (On the Hospital) LD……………… or US$

(3) Medication (Outside the Hospital) LD……………… or US$

(4) Other (Specify)…………………………… LD……………… or US$

26. If you did pay for any services, how did you find the payment?

(0) Expensive

(1) Affordable

27. If the facility is a fee for service, ask if:

The patient saw a price list pasted up in the health facility?

Total Score Attained=

Maximum possible score=

Ask the following questions to the patient from their experiences in visiting the health facility

28. In summary what can you describe as positive (encouraging) from your visit to the Hospital?

29. What do you think are the weaknesses from your point of view?

30. What do you think should be done to improve service at the Hospital?

Interviewer Name : _________________________ Signature /Date : _____________________