Patient Satisfaction Survey

	Jan	Feb	Mar	Apr	May	June	July	Aug	Sept	Oct	Nov	Dec
What Month was your procedure performed?	*What month was your procedure performed? What Month was your procedure performed? Jan	What Month was your procedure performed? Feb	What Month was your procedure performed? Mar	What Month was your procedure performed? Apr	What Month was your procedure performed? May	What Month was your procedure performed? June	What Month was your procedure performed? July	What Month was your procedure performed? Aug	What Month was your procedure performed? Sept	What Month was your procedure performed? Oct	What Month was your procedure performed? Nov	What Month was your procedure performed? Dec

2. Procedure

	Surgery	Pain Management
What type of procedure did you receive?	*Procedure What type of procedure did you receive? Surgery	What type of procedure did you receive? Pain Management

3. How would you rate the following aspects of our facility?

	Dissatisfied	Average	Above Average	Exceeds	N/A
Cleanliness	*How would you rate the following aspects of our facility? Cleanliness Dissatisfied	Cleanliness Average	Cleanliness Above Average	Cleanliness Exceeds	Cleanliness N/A
Decor & Attractiveness	Decor & Attractiveness Dissatisfied	Decor & Attractiveness Average	Decor & Attractiveness Above Average	Decor & Attractiveness Exceeds	Decor & Attractiveness N/A
Comfort of lobby	Comfort of lobby Dissatisfied	Comfort of lobby Average	Comfort of lobby Above Average	Comfort of lobby Exceeds	Comfort of lobby N/A
Comfort of patient care area	Comfort of patient care area Dissatisfied	Comfort of patient care area Average	Comfort of patient care area Above Average	Comfort of patient care area Exceeds	Comfort of patient care area N/A

Any comments or suggestions (Please elaborate on any item with a low score)

4. How would you rate our staff in the following areas?

	Dissastisfied	Average	Above Average	Exceeds	N/A
Courtesy of receptionist	*How would you rate our staff in the following areas? Courtesy of receptionist Dissastisfied	Courtesy of receptionist Average	Courtesy of receptionist Above Average	Courtesy of receptionist Exceeds	Courtesy of receptionist N/A
Courtesy of pre-op, operating room and recovery staff	Courtesy of pre-op, operating room and recovery staff Dissastisfied	Courtesy of pre-op, operating room and recovery staff Average	Courtesy of pre-op, operating room and recovery staff Above Average	Courtesy of pre-op, operating room and recovery staff Exceeds	Courtesy of pre-op, operating room and recovery staff N/A
Nursing staff knowledge and competence	Nursing staff knowledge and competence Dissastisfied	Nursing staff knowledge and competence Average	Nursing staff knowledge and competence Above Average	Nursing staff knowledge and competence Exceeds	Nursing staff knowledge and competence N/A
Nursing pre-operative instructions	Nursing pre-operative instructions Dissastisfied	Nursing pre-operative instructions Average	Nursing pre-operative instructions Above Average	Nursing pre-operative instructions Exceeds	Nursing pre-operative instructions N/A
Nurse's discharge instructions	Nurse's discharge instructions Dissastisfied	Nurse's discharge instructions Average	Nurse's discharge instructions Above Average	Nurse's discharge instructions Exceeds	Nurse's discharge instructions N/A
Helpfulness of post-op phone call	Helpfulness of post-op phone call Dissastisfied	Helpfulness of post-op phone call Average	Helpfulness of post-op phone call Above Average	Helpfulness of post-op phone call Exceeds	Helpfulness of post-op phone call N/A
Courtesy of anesthesiologist	Courtesy of anesthesiologist Dissastisfied	Courtesy of anesthesiologist Average	Courtesy of anesthesiologist Above Average	Courtesy of anesthesiologist Exceeds	Courtesy of anesthesiologist N/A
Anesthesiologist's explanations prior to surgery	Anesthesiologist's explanations prior to surgery Dissastisfied	Anesthesiologist's explanations prior to surgery Average	Anesthesiologist's explanations prior to surgery Above Average	Anesthesiologist's explanations prior to surgery Exceeds	Anesthesiologist's explanations prior to surgery N/A
Courtesy of surgeon	Courtesy of surgeon Dissastisfied	Courtesy of surgeon Average	Courtesy of surgeon Above Average	Courtesy of surgeon Exceeds	Courtesy of surgeon N/A
Surgeon's explanations before surgery	Surgeon's explanations before surgery Dissastisfied	Surgeon's explanations before surgery Average	Surgeon's explanations before surgery Above Average	Surgeon's explanations before surgery Exceeds	Surgeon's explanations before surgery N/A

Any comments or suggestions (Please elaborate on any item with a low score)

5. Your care

	Dissatisfied	Average	Above average	Exceeds	N/A
How well was your pain controlled while you were our patient?	*Your care How well was your pain controlled while you were our patient? Dissatisfied	How well was your pain controlled while you were our patient? Average	How well was your pain controlled while you were our patient? Above average	How well was your pain controlled while you were our patient? Exceeds	How well was your pain controlled while you were our patient? N/A
Was your privacy respected?	Was your privacy respected? Dissatisfied	Was your privacy respected? Average	Was your privacy respected? Above average	Was your privacy respected? Exceeds	Was your privacy respected? N/A
Were the person(s) waiting for you kept informed?	Were the person(s) waiting for you kept informed? Dissatisfied	Were the person(s) waiting for you kept informed? Average	Were the person(s) waiting for you kept informed? Above average	Were the person(s) waiting for you kept informed? Exceeds	Were the person(s) waiting for you kept informed? N/A
Did your ride (family/friend) feel that the discharge information given was helpful?	Did your ride (family/friend) feel that the discharge information given was helpful? Dissatisfied	Did your ride (family/friend) feel that the discharge information given was helpful? Average	Did your ride (family/friend) feel that the discharge information given was helpful? Above average	Did your ride (family/friend) feel that the discharge information given was helpful? Exceeds	Did your ride (family/friend) feel that the discharge information given was helpful? N/A
How would you rate your confidence in the care you received?	How would you rate your confidence in the care you received? Dissatisfied	How would you rate your confidence in the care you received? Average	How would you rate your confidence in the care you received? Above average	How would you rate your confidence in the care you received? Exceeds	How would you rate your confidence in the care you received? N/A
Was the pre-op phone call helpful in preparing for your post-op care?	Was the pre-op phone call helpful in preparing for your post-op care? Dissatisfied	Was the pre-op phone call helpful in preparing for your post-op care? Average	Was the pre-op phone call helpful in preparing for your post-op care? Above average	Was the pre-op phone call helpful in preparing for your post-op care? Exceeds	Was the pre-op phone call helpful in preparing for your post-op care? N/A

Any comments or suggestions (Please elaborate on any item with a low score)

6. Administrative

	Dissatisfied	Average	Above Average	Exceeds	N/A
Was the scheduling process convenient?	*Administrative Was the scheduling process convenient? Dissatisfied	Was the scheduling process convenient? Average	Was the scheduling process convenient? Above Average	Was the scheduling process convenient? Exceeds	Was the scheduling process convenient? N/A
An adequate explanation of the billing process was provided in your pre-op packet.	An adequate explanation of the billing process was provided in your pre-op packet. Dissatisfied	An adequate explanation of the billing process was provided in your pre-op packet. Average	An adequate explanation of the billing process was provided in your pre-op packet. Above Average	An adequate explanation of the billing process was provided in your pre-op packet. Exceeds	An adequate explanation of the billing process was provided in your pre-op packet. N/A
I was informed of any deductibles, co-insurance or co-pays due before surgery (If you did not have a co-pay or deductible, there was no notification).	I was informed of any deductibles, co-insurance or co-pays due before surgery (If you did not have a co-pay or deductible, there was no notification). Dissatisfied	I was informed of any deductibles, co-insurance or co-pays due before surgery (If you did not have a co-pay or deductible, there was no notification). Average	I was informed of any deductibles, co-insurance or co-pays due before surgery (If you did not have a co-pay or deductible, there was no notification). Above Average	I was informed of any deductibles, co-insurance or co-pays due before surgery (If you did not have a co-pay or deductible, there was no notification). Exceeds	I was informed of any deductibles, co-insurance or co-pays due before surgery (If you did not have a co-pay or deductible, there was no notification). N/A

Any comments or suggestions (Please elaborate on any item with a low score)

7. Do you feel confident in referring family and friends to our facility?

Do you feel confident in referring family and friends to our facility? Yes	No
If no, please elaborate

Thank you for your assistance. It is our goal to use this information to better serve our customers. If you wish to speak to someone regarding your care or would like to file a formal grievance, please fill in the information below or contact Vicky Burrack, Clinical Director of Front Range Orthopedic Surgery Center at (720) 494-3201.

8. Provide your information below if you would like to be contacted by the Clinical Director.

Provide your information below if you would like to be contacted by the Clinical Director. Name:
Email Address:
Phone Number:

Patient Satisfaction
Exit this survey

1. Patient Satisfaction Survey

1. What month was your procedure performed?

2. Procedure

3. How would you rate the following aspects of our facility?

4. How would you rate our staff in the following areas?

5. Your care

6. Administrative

7. Do you feel confident in referring family and friends to our facility?

8. Provide your information below if you would like to be contacted by the Clinical Director.

Patient SatisfactionExit this survey

1. Patient Satisfaction Survey

1. What month was your procedure performed?

2. Procedure

3. How would you rate the following aspects of our facility?

4. How would you rate our staff in the following areas?

5. Your care

6. Administrative

7. Do you feel confident in referring family and friends to our facility?

8. Provide your information below if you would like to be contacted by the Clinical Director.

Patient Satisfaction
Exit this survey