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Patient Safety Tool: HRSA Patient Satisfaction Survey

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The Health Resources and Services Administration has developed a sample patient satisfaction survey form.

 

This survey form may be downloaded, modified, printed and distributed to patients.

 

Download the HRSA English patient satisfaction survey (doc) and adapt it for use in your facility. Download the HRSA Spanish patient satisfaction survey (doc).

 

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To ensure consistency in the administration of the patient satisfaction survey, HRSA suggests that the survey be given to patients in one of three ways listed below.

  • A stack of the surveys is made readily available to patients at the time they check out from the organization. If the surveys are administered this way, have an envelope or box, marked "Completed Patient Satisfaction Surveys," right next to the stack of surveys, 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 organization. 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 Surveys," to place the survey in.
  • If patients have difficulty reading, someone who is not a healthcare provider at your organization should assist them. If appropriate, staff members should ask patients if they need help to complete the survey. Individuals that can assist patients in reading the survey include outreach workers, non-healthcare 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 Surveys," 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.

 

Related Articles on Patient Safety Tools:

SCIP 'Stop Antibiotics' Poster

Hand Hygiene and Glove Use Monitoring Form

5 Safe Injection Practices Posters

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