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Hospice House Room Refresh
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1.
Which descriptor best identifies you?
(Required.)
Patient
Family/friend
Staff/volunteer
2.
Rate the lighting and lighting adjustment options for the room.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
3.
Rate the brightness of the room. Does the room appear open, bright, and inviting?
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
4.
Rate the bed functions. Does it meet patient needs?
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
5.
Rate the comfort of the bed.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
6.
Rate the bathroom function and aesthetics for meeting needs.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
7.
Rate the TV. Does it meet the patient's needs?
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
8.
Rate the function and comfort of the sleep recliner.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
9.
Rate the function and comfort of the sleep sofa.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
10.
Rate the fixed benches (if applicable) in regards to comfort and function.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
N/A
Other (please specify)
11.
Rate the folding chairs and their storage options.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
12.
How likely will the Nurse/Patient information board benefit the patient/family experience?
Not likely at all to be beneficial.
1 star
Could be beneficial.
2 stars
Somewhat beneficial.
3 stars
Very beneficial.
4 stars
Other (please specify)
13.
Rate the amenities such as USB ports and lamps. Do these meet needs?
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
14.
Is there an amenity that we should consider adding to enhance the patient/family experience?
15.
Rate your overall impression of the room.
Poor
1 star
Acceptable
2 stars
Good
3 stars
Superior
4 stars
Other (please specify)
Current Progress,
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