Outpatient Specialty ClinicsExcelsior Springs Hospital Survey

Question Title

* 2. Rate your overall experience?

Excellent

Very Good

Good

Fair

Poor

Question Title

* 3. Would you recommend our department to your family and friends?

Yes

Question Title

* 4. Did you have any difficulties scheduling your appointment?

Yes

Question Title

* 5. Once you registered for your scheduled appointment your wait time to be seen in clinic was?

Less than 5 minutes

5-10 minutes

10-15 minutes

15 minutes or more

Question Title

* 6. During your visit how often did staff treat you with courtesy and respect?

Always

Usually

Sometimes

Never

Question Title

* 7. During your visit how often did staff listen carefully to you?

Always

Usually

Sometimes

Never

Question Title

* 8. During your visit how often did staff explain things in a way you could understand?

Always

Usually

Sometimes

Never

Question Title

* 9. The cleanliness and comfort of the department was:

Excellent

Very Good

Good

Fair

Poor

Question Title

* 10. During your visit how often did staff maintain your privacy?

Always

Usually

Sometimes

Never

Question Title

* 11. For Procedure Patients only: Were your pre-procedure instructions clear and provide the necessary information?

Yes

Other (please specify)

Question Title

* 12. For Procedure Patients only: Were your post-procedure instructions clear and provide the necessary information?

Yes

Other (please specify)

Question Title

* 13. If you utilized services in other departments for this visit, please rate your experience:

	Excellent	Very Good	Good	Fair	Poor	N/A
Admitting/Registration	Admitting/Registration Excellent	Admitting/Registration Very Good	Admitting/Registration Good	Admitting/Registration Fair	Admitting/Registration Poor	Admitting/Registration N/A
Laboratory	Laboratory Excellent	Laboratory Very Good	Laboratory Good	Laboratory Fair	Laboratory Poor	Laboratory N/A
Radiology	Radiology Excellent	Radiology Very Good	Radiology Good	Radiology Fair	Radiology Poor	Radiology N/A
Cardiopulmonary	Cardiopulmonary Excellent	Cardiopulmonary Very Good	Cardiopulmonary Good	Cardiopulmonary Fair	Cardiopulmonary Poor	Cardiopulmonary N/A

Question Title

* 14. Other comments:

Please take an Everyone Shines Here comment card to acknowledge
a staff member who deserves recognition.

Question Title

* 15. Date of visit (optional)

Date

Question Title

* 16. Contact information (optional)

Name

Phone number

Email address

Thank you for taking the time to fill out our survey so that we may improve our services to our patients. Your suggestions are very important to us.

If you have additional information or concerns please feel free to contact:

Outpatient Director

816-629-3524

Outpatient Specialty Clinics
Excelsior Springs Hospital

Question Title

* 1. Please indicate the service you were seen for:

Question Title

* 2. Rate your overall experience?

Question Title

* 3. Would you recommend our department to your family and friends?

Question Title

* 4. Did you have any difficulties scheduling your appointment?

Question Title

* 5. Once you registered for your scheduled appointment your wait time to be seen in clinic was?

Question Title

* 6. During your visit how often did staff treat you with courtesy and respect?

Question Title

* 7. During your visit how often did staff listen carefully to you?

Question Title

* 8. During your visit how often did staff explain things in a way you could understand?

Question Title

* 9. The cleanliness and comfort of the department was:

Question Title

* 10. During your visit how often did staff maintain your privacy?

Question Title

* 11. For Procedure Patients only: Were your pre-procedure instructions clear and provide the necessary information?

Question Title

* 12. For Procedure Patients only: Were your post-procedure instructions clear and provide the necessary information?

Question Title

* 13. If you utilized services in other departments for this visit, please rate your experience:

Question Title

* 14. Other comments:

Question Title

* 15. Date of visit (optional)

Question Title

* 16. Contact information (optional)