Patient Experience Survey

Please complete this survey to help us improve our care and services in order to achieve our mission:

Committed to compassionate, forward-thinking, quality-driven, and safe health care that honors the community

Contact GMHA Guest Relations

Phone 671-647-2503/671-648-7981 or Email guestrelations@gmha.org

Yes, I would like to participate in GMHA's raffle.

Would you like to participate in GMHA's raffle drawing?

(Both your name and contact number required. Must be 18 years old and above to participate)

Yes, I would like to participate in GMHA's raffle.

Name of Patient or Guardian of Minor Patient

Contact Info

Contact Info

Contact Number

Email Address

Date of Admission

mm/dd/yyyy

Demographic Info

Demographic Info

Gender

Male

Female

Age

18-39

40-59

60-79

80 and Above

What is your racial background

What language do you speak at home?

Highest Level of School Completed

How would you rate your overall health

Please indicate how often each was provided

General Impressions of GMH

General Impressions of GMH

Recommend GMH to family and friends?

Always

Usually

Sometimes

Never

Treatment received met my expectations?

Always

Usually

Sometimes

Never

Referred to this survey by:

Interaction with Hospital Staff

Interaction with Hospital Staff

Registration Department

Registration Department

1. Often Treated with Courtesy and Respect

Always

Usually

Sometimes

Never

2. Concerns and Needs Often Promptly Addressed

Always

Usually

Sometimes

Never

3. Carefully Listened to You

Always

Usually

Sometimes

Never

4. Explained Things in a Way You Could Understand

Always

Usually

Sometimes

Never

Nursing

Nursing

Nurse's Name

Ward patient received care from a Nurse

5. Often Treated with Courtesy and Respect

Always

Usually

Sometimes

Never

6. Concerns and Needs Often Promptly Addressed

Always

Usually

Sometimes

Never

7. Carefully Listened to You

Always

Usually

Sometimes

Never

8. Explained Things in a Way You Could Understand

Always

Usually

Sometimes

Never

Doctor's Services

Doctor's Services

Doctor's Name

9. Often Treated with Courtesy and Respect

Always

Usually

Sometimes

Never

10. Concerns and Needs Often Promptly Addressed

Always

Usually

Sometimes

Never

11. Carefully Listened to You

Always

Usually

Sometimes

Never

12. Explained Things in a Way You Could Understand

Always

Usually

Sometimes

Never

Billing Department

Billing Department

13. Often Treated with Courtesy and Respect

Always

Usually

Sometimes

Never

14. Concerns and Needs Often Promptly Addressed

Always

Usually

Sometimes

Never

15. Carefully Listened to You

Always

Usually

Sometimes

Never

16. Explained Things in a Way You Could Understand

Always

Usually

Sometimes

Never

In-House Care

In-House Care

Hospitality Services provided to you during your stay

Cleanliness

Cleanliness

House Keeping Services

17. Often Treated with Courtesy and Respect

Always

Usually

Sometimes

Never

18. Concerns and Needs Promptly Addressed

Always

Usually

Sometimes

Never

19. Patient Room Cleanliness

Always

Usually

Sometimes

Never

20. Public Restroom Cleanliness

Always

Usually

Sometimes

Never

Hospital Environment

Hospital Environment

Accommodations

21. Room Temperature/ Lighting

Always

Usually

Sometimes

Never

22. Noise Level Minimized

Always

Usually

Sometimes

Never

23. All Equipment Works

Always

Usually

Sometimes

Never

24. Room Assignment

Always

Usually

Sometimes

Never

Food

Food

Quality of the Food

25. Looks/ Tastes Appetizing

Always

Usually

Sometimes

Never

26. Proper Temperature

Always

Usually

Sometimes

Never

27. Portion Size

Always

Usually

Sometimes

Never

28. Preferences Followed

Always

Usually

Sometimes

Never

Pain Control

Pain Control

29. How well was your pain controlled?

Always

Usually

Sometimes

Never

30. Was medicine provided as needed?

Always

Usually

Sometimes

Never

31. The hospital staff helped with pain control

The hospital staff did everything they could to help with the pain.

Always

Usually

Sometimes

Never

Assisted Restroom Use

Assisted Restroom Use

32. Assisted Restroom Use

How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

Always

Usually

Sometimes

Never

Discharge

Discharge

33. After Discharge Care

During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

Always

Usually

Sometimes

Never

Other Hospital Services

Other Hospital Services

Outpatient and Other Services (click yes to see these services)

Did you receive other hospital services?

yes

no

Privacy/ Language

Privacy/ Language

34. Privacy

Staff kept my medical condition and treatment private.

Always

Usually

Sometimes

Never

35. Language of choice

My health care needs were discussed in the language of my choice.

Always

Usually

Sometimes

Never

Comments

Comments

How did we do? We want to hear from you!

Send me a copy of my responses