OB Patient Survey

1. Patient Satisfaction Survey "Birthing Services"

When you complete this form, you will help our staff see themselves through your eyes. We need your criticism and suggestions as well as your praise Thank you for your honest responses.

1. Was this pregnancy the first time you were seen by our Nurse-Midwives?

Was this pregnancy the first time you were seen by our Nurse-Midwives?

Other (please specify)

2. How did you first hear about WBWC?

How did you first hear about WBWC?

3. What was your main reason for choosing to come to the Birth Center?

What was your main reason for choosing to come to the Birth Center?

4. Please rate our staff on competency, attitudes, and sensitivity to your needs (comments welcome):

	Excellent	Good	Adequate	Needs Improvement	N/A
Providers (FNP, CNMs)	*Please rate our staff on competency, attitudes, and sensitivity to your needs (comments welcome): Providers (FNP, CNMs) Excellent	Providers (FNP, CNMs) Good	Providers (FNP, CNMs) Adequate	Providers (FNP, CNMs) Needs Improvement	Providers (FNP, CNMs) N/A
Nurses (RNs)	Nurses (RNs) Excellent	Nurses (RNs) Good	Nurses (RNs) Adequate	Nurses (RNs) Needs Improvement	Nurses (RNs) N/A
Laboratory	Laboratory Excellent	Laboratory Good	Laboratory Adequate	Laboratory Needs Improvement	Laboratory N/A
Administration/ Clerical	Administration/ Clerical Excellent	Administration/ Clerical Good	Administration/ Clerical Adequate	Administration/ Clerical Needs Improvement	Administration/ Clerical N/A

Other (please specify)

5. My baby was born at

My baby was born at WBWC

UNC

Other (please specify)

6. The CNM and RN attending my birth were

The CNM and RN attending my birth were

7. Rate your experience for/ your impression of the following services:

	Excellent	Good	Adequate	Needs Improvement	N/A
Availability of Appointments	*Rate your experience for/ your impression of the following services: Availability of Appointments Excellent	Availability of Appointments Good	Availability of Appointments Adequate	Availability of Appointments Needs Improvement	Availability of Appointments N/A
Telephone Answering	Telephone Answering Excellent	Telephone Answering Good	Telephone Answering Adequate	Telephone Answering Needs Improvement	Telephone Answering N/A
Orientation Tour	Orientation Tour Excellent	Orientation Tour Good	Orientation Tour Adequate	Orientation Tour Needs Improvement	Orientation Tour N/A
Initial Visit	Initial Visit Excellent	Initial Visit Good	Initial Visit Adequate	Initial Visit Needs Improvement	Initial Visit N/A
Prenatal Care	Prenatal Care Excellent	Prenatal Care Good	Prenatal Care Adequate	Prenatal Care Needs Improvement	Prenatal Care N/A
Lab Work	Lab Work Excellent	Lab Work Good	Lab Work Adequate	Lab Work Needs Improvement	Lab Work N/A
Supportive Environment	Supportive Environment Excellent	Supportive Environment Good	Supportive Environment Adequate	Supportive Environment Needs Improvement	Supportive Environment N/A
Family Inclusiveness	Family Inclusiveness Excellent	Family Inclusiveness Good	Family Inclusiveness Adequate	Family Inclusiveness Needs Improvement	Family Inclusiveness N/A
Opportunity to participate in decison making	Opportunity to participate in decison making Excellent	Opportunity to participate in decison making Good	Opportunity to participate in decison making Adequate	Opportunity to participate in decison making Needs Improvement	Opportunity to participate in decison making N/A
Sufficient Explanations & Teaching	Sufficient Explanations & Teaching Excellent	Sufficient Explanations & Teaching Good	Sufficient Explanations & Teaching Adequate	Sufficient Explanations & Teaching Needs Improvement	Sufficient Explanations & Teaching N/A
Library	Library Excellent	Library Good	Library Adequate	Library Needs Improvement	Library N/A
Breastfeeding information & Support	Breastfeeding information & Support Excellent	Breastfeeding information & Support Good	Breastfeeding information & Support Adequate	Breastfeeding information & Support Needs Improvement	Breastfeeding information & Support N/A
Postpartum Care & Support after leaving Center	Postpartum Care & Support after leaving Center Excellent	Postpartum Care & Support after leaving Center Good	Postpartum Care & Support after leaving Center Adequate	Postpartum Care & Support after leaving Center Needs Improvement	Postpartum Care & Support after leaving Center N/A
Emergency Equipment	Emergency Equipment Excellent	Emergency Equipment Good	Emergency Equipment Adequate	Emergency Equipment Needs Improvement	Emergency Equipment N/A
Transfer to UNC (if applicable)	Transfer to UNC (if applicable) Excellent	Transfer to UNC (if applicable) Good	Transfer to UNC (if applicable) Adequate	Transfer to UNC (if applicable) Needs Improvement	Transfer to UNC (if applicable) N/A
Physical facilities	Physical facilities Excellent	Physical facilities Good	Physical facilities Adequate	Physical facilities Needs Improvement	Physical facilities N/A
Cleanliness	Cleanliness Excellent	Cleanliness Good	Cleanliness Adequate	Cleanliness Needs Improvement	Cleanliness N/A

Other (please specify)

8. What suggestions do you have to improve our services?

What suggestions do you have to improve our services?

9. Would you recommend the Birth Center to your friends?

	1) Not Likely At All	2)	3)	4)	5)	6)	7)	8)	9)	10) Extremely Likely
On a 10pt. Scale	*Would you recommend the Birth Center to your friends? On a 10pt. Scale 1) Not Likely At All	On a 10pt. Scale 2)	On a 10pt. Scale 3)	On a 10pt. Scale 4)	On a 10pt. Scale 5)	On a 10pt. Scale 6)	On a 10pt. Scale 7)	On a 10pt. Scale 8)	On a 10pt. Scale 9)	On a 10pt. Scale 10) Extremely Likely

Why/ Why Not?

10. What would you like to have happen differently at your next birth should you decide to have another baby? Any final comments please note below as well.

What would you like to have happen differently at your next birth should you decide to have another baby? Any final comments please note below as well.

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1. Patient Satisfaction Survey "Birthing Services"

OB Patient
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