Palliative Care Survey for Hospitals in Georgia

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1. Hospital Name

Hospital Name

2. Location

Location

3. Number of beds

Number of beds

4. Status

Status   For profit Not for profit

5. How would you describe your palliative care service?

How would you describe your palliative care service?

6. Are palliative care program staff integrated into the hospital management?

Are palliative care program staff integrated into the hospital management?   Yes No

7. Are the palliative care consultation services available to:

	Yes	No
All hospital inpatients?	Are the palliative care consultation services available to: All hospital inpatients? Yes	All hospital inpatients? No
Outpatients?	Outpatients? Yes	Outpatients? No

8. Do you have a designated inpatient palliative care unit?

Do you have a designated inpatient palliative care unit?   Yes No

9. If so, how many rooms?

If so, how many rooms?

10. How many beds?

How many beds?

11. Is palliative care inpatient consultation available Monday-Friday?

Is palliative care inpatient consultation available Monday-Friday?   Yes No

12. Is palliative care inpatient consultation available 24/7?

Is palliative care inpatient consultation available 24/7?   Yes No

13. If not, is it available by telephone support 24/7?

If not, is it available by telephone support 24/7?   Yes No

14. Do you have a designated palliative care physician?

Do you have a designated palliative care physician?   Yes No

15. Is this physician board-certified in hospice and palliative medicine?

Is this physician board-certified in hospice and palliative medicine?   Yes No

16. If not, are they working toward board certification?

If not, are they working toward board certification?   Yes No

17. Do you have a designated palliative care nurse?

Do you have a designated palliative care nurse?   Yes No

18. Is the nurse(s) an advance practice nurse?

Is the nurse(s) an advance practice nurse?   Yes No

19. Are the program nurses certified by the National Board for Certification of Hospice and Palliative Nursing (NBCHPN)?

Are the program nurses certified by the National Board for Certification of Hospice and Palliative Nursing (NBCHPN)?   Yes No

20. If not, are they working toward board certification?

If not, are they working toward board certification?   Yes No

21. Do you have any of the following types of measures in place for your palliative care program?

	Yes	No
Patient and family satisfaction?	Do you have any of the following types of measures in place for your palliative care program? Patient and family satisfaction? Yes	Patient and family satisfaction? No
Clinical?	Clinical? Yes	Clinical? No
Financial?	Financial? Yes	Financial? No

22. Do you have quality improvement activities going on in your palliative care program, either continuously or intermittently, related to:

	Yes	No
Pain management?	Do you have quality improvement activities going on in your palliative care program, either continuously or intermittently, related to: Pain management? Yes	Pain management? No
Non-pain symptoms?	Non-pain symptoms? Yes	Non-pain symptoms? No
Psychosocial/spiritual distress?	Psychosocial/spiritual distress? Yes	Psychosocial/spiritual distress? No
Communication between healthcare providers and patients/surrogates?	Communication between healthcare providers and patients/surrogates? Yes	Communication between healthcare providers and patients/surrogates? No

23. Do you have and use palliative care marketing materials for:

	Yes	No
Hospital staff?	Do you have and use palliative care marketing materials for: Hospital staff? Yes	Hospital staff? No
Patients?	Patients? Yes	Patients? No
Families?	Families? Yes	Families? No

24. Does your hospital provide palliative care educational resources to key staff?

Does your hospital provide palliative care educational resources to key staff?   Yes No

25. Do you have a bereavement policy and procedure that describes bereavement services provided to families of palliative care patients?

Do you have a bereavement policy and procedure that describes bereavement services provided to families of palliative care patients?   Yes No

26. Do you have relationships in place to allow palliative care screening to occur in:

	Yes	No
The Emergency Department?	Do you have relationships in place to allow palliative care screening to occur in: The Emergency Department? Yes	The Emergency Department? No
General med/surgical units?	General med/surgical units? Yes	General med/surgical units? No
Intensive care units?	Intensive care units? Yes	Intensive care units? No

27. Do you have specific policies in place to facilitate transitions across care sites?

Do you have specific policies in place to facilitate transitions across care sites?   Yes No

28. Do you have a working relationship with at least one community hospice provider?

Do you have a working relationship with at least one community hospice provider?   Yes No

29. Do you have policies and procedures to address and promote palliative care team wellness?

Do you have policies and procedures to address and promote palliative care team wellness?   Yes No

30. How many patients do you have who are currently receiving palliative care?

How many patients do you have who are currently receiving palliative care?

31. What is your level of satisfaction with the palliative care program right now?

What is your level of satisfaction with the palliative care program right now?   Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied

32. Are there any suggestions for improvement or anything else you would like to add?

Are there any suggestions for improvement or anything else you would like to add?

33. Would you like to have a copy of the results of this study? If so, please provide name and address, including email address.

Would you like to have a copy of the results of this study? If so, please provide name and address, including email address.