Satisfaction Survey

Satisfaction Survey - Post Admission

- Step 1 of 4

Survey Code *

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Demographics

Name

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I am the... *

Overall Satisfaction with Hospice Experience

Your Experience *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Overall, how would you rate your experience with Savior Hospice & Palliative Care?

How can we improve?

We're sorry to hear that you did not have a good experience. Please let us know how we can do better.

Survey Criteria

Please indicate the appropriate response which best describes your opinion. *

	Not Applicable/No Opinion	Strongly Disagree	Disagree	Agree	Strongly Agree
We were satisfied with the care provided by the hospice staff.	We were satisfied with the care provided by the hospice staff. Not Applicable/No Opinion	We were satisfied with the care provided by the hospice staff. Strongly Disagree	We were satisfied with the care provided by the hospice staff. Disagree	We were satisfied with the care provided by the hospice staff. Agree	We were satisfied with the care provided by the hospice staff. Strongly Agree
Medication/Supplies were delivered on time.	Medication/Supplies were delivered on time. Not Applicable/No Opinion	Medication/Supplies were delivered on time. Strongly Disagree	Medication/Supplies were delivered on time. Disagree	Medication/Supplies were delivered on time. Agree	Medication/Supplies were delivered on time. Strongly Agree
Equipment was delivered on time.	Equipment was delivered on time. Not Applicable/No Opinion	Equipment was delivered on time. Strongly Disagree	Equipment was delivered on time. Disagree	Equipment was delivered on time. Agree	Equipment was delivered on time. Strongly Agree
We were involved in decision making regarding the plan of care for our family.	We were involved in decision making regarding the plan of care for our family. Not Applicable/No Opinion	We were involved in decision making regarding the plan of care for our family. Strongly Disagree	We were involved in decision making regarding the plan of care for our family. Disagree	We were involved in decision making regarding the plan of care for our family. Agree	We were involved in decision making regarding the plan of care for our family. Strongly Agree
Staff treated our family, our home, and belongings with respect.	Staff treated our family, our home, and belongings with respect. Not Applicable/No Opinion	Staff treated our family, our home, and belongings with respect. Strongly Disagree	Staff treated our family, our home, and belongings with respect. Disagree	Staff treated our family, our home, and belongings with respect. Agree	Staff treated our family, our home, and belongings with respect. Strongly Agree
Staff explained care, services, rights and responsibilities, and other procedures related to the care provided.	Staff explained care, services, rights and responsibilities, and other procedures related to the care provided. Not Applicable/No Opinion	Staff explained care, services, rights and responsibilities, and other procedures related to the care provided. Strongly Disagree	Staff explained care, services, rights and responsibilities, and other procedures related to the care provided. Disagree	Staff explained care, services, rights and responsibilities, and other procedures related to the care provided. Agree	Staff explained care, services, rights and responsibilities, and other procedures related to the care provided. Strongly Agree
We were able to reach hospice staff in a timely manner whenever necessary.	We were able to reach hospice staff in a timely manner whenever necessary. Not Applicable/No Opinion	We were able to reach hospice staff in a timely manner whenever necessary. Strongly Disagree	We were able to reach hospice staff in a timely manner whenever necessary. Disagree	We were able to reach hospice staff in a timely manner whenever necessary. Agree	We were able to reach hospice staff in a timely manner whenever necessary. Strongly Agree
We would recommend this hospice to friends and relatives.	We would recommend this hospice to friends and relatives. Not Applicable/No Opinion	We would recommend this hospice to friends and relatives. Strongly Disagree	We would recommend this hospice to friends and relatives. Disagree	We would recommend this hospice to friends and relatives. Agree	We would recommend this hospice to friends and relatives. Strongly Agree
Staff provided emotional support during our hospice experience.	Staff provided emotional support during our hospice experience. Not Applicable/No Opinion	Staff provided emotional support during our hospice experience. Strongly Disagree	Staff provided emotional support during our hospice experience. Disagree	Staff provided emotional support during our hospice experience. Agree	Staff provided emotional support during our hospice experience. Strongly Agree
Staff assisted with managing our loved one/family members pain & symptom control.	Staff assisted with managing our loved one/family members pain & symptom control. Not Applicable/No Opinion	Staff assisted with managing our loved one/family members pain & symptom control. Strongly Disagree	Staff assisted with managing our loved one/family members pain & symptom control. Disagree	Staff assisted with managing our loved one/family members pain & symptom control. Agree	Staff assisted with managing our loved one/family members pain & symptom control. Strongly Agree

Did the hospice team explain the plan of care to you in a way that you could understand?

While under the care of hospice, was there always one nurse who was identified as being in charge of the patient’s overall care?

Based on the care the patient received, would you recommend this hospice to others?

Definitely No	Probably No	Probably Yes	Definitely Yes
Item #1 Definitely No	Item #1 Probably No	Item #1 Probably Yes	Item #1 Definitely Yes

Is there anything else that you would like to tell us about the care provided by the hospice team?

Please contact me

Please have a member of the Hospice Leadership Team contact me regarding this survey.

Please provide a telephone number where you can be reached

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