INTERVIEW SCHEDULE FOR PATIENTS

I. PERSONAL PEOPLE
1.1. Name and address :

1.2. Age : a) up to 20 years b) 21 – 30 years

c) 31 – 40 years d) 41 – 50 years
e) 51 – 60 years f) 61 years & above

1.3. Sex : a) Male b) Female

1.4. Educational Qualification : a) Illiterate b) Primary Level

c) HSC Level d) Graduation Level
e) Diplomo Level f) Post Graduation Level
g) Professional Level.

1.5. Occupation Status : a) Agriculturist b) Business

c) Employees d) Professional
e) House Wife f) Student
f) Retired Person.

1.6. Monthly Family Income : a) Up to Rs.5,000/- b) Rs.5000 - 10,000/-

b) Rs.10,000 – 15,000/- d) Rs.15,000 – 20,000/-
e) Rs.20,000 – 25,000/- f) Rs.25,000 and above.

1.7. Area of residence : a) Urban b) Rural

1.8. Nature of treatment :

II. AWARNESS:

2.1 a) Are you aware of the following medical and surgical service offered
by the hospital? Yes / No
b) If yes, tick the service that you are aware of

S.No Medical S.No Surgical

1 General 1 General
2 Cancer 2 Cardiac Surgery
3 Cardiology 3 Dental
4 Dermatology 4 ENT
5 Diabetes 5 Gynecology & Obstetrics
6 Gastro Eterology 6 Neuro Surgery
7 Heamatology 7 Orthopedics
8 Nephrology / Urology 8 Ophthalmology
9 Neurology 9 Plastic/Cosmetic Surgery
10 Paediatrics
11 Psychiatry
12 Pulmonology
13 Rheumatology

2.2 a) Are you aware of the supportive services offered by the hospital?
Yes / No
b) If yes, specify the services offered by the hospital which you are aware of
S.No Service S.No Service
1 Ambulance 7 Laboratory
2 Blood Bank 8 Nursing
3 Canteen 9 Operation Theater
4 Dietary 10 Pharmacy
5 House Keeping 11 Radiology
6 ICU 12 Registration

2.3 a) Are you aware of the following Hospital Charges? Yes / No

b) If yes specify the charges that you are aware of
S.No Charges S.No Charges
1 Physician Charges 6 Parking Charges
2 Radiology / Laboratory 7 Nursing Charges
3 Registration 8 Room Rent
4 Medicines 9 ICU Charges
5 Canteen Rates 10 Dietary Charges

2.4. How did you come to know about this hospital, its service and charges?
a) Advertisement b) Employees of the Hospital
c) Private Practitioners d) Other Patients
e) Share Holders f) Prime Location
g) Health Camps h) Friends and Relatives.

2.5. If through advertisement, which media

a) Newspaper and magazines b) Radio and TV
c) Banners, Posters etc. d) Web

2.6. Reasons for selection of this Hospital

(If more than one factor, rank them)
S.No Reasons for selection Rank
1 Private Physician’s advice
2 Reputation of the Physician concerned in the hospital
3 Reputation of the hospital
4 Nearness of the hospital to the patients residence
5 Lower charges compared to the other hospital
6 Facilities and care available in the hospital
7 Concessions offered by the hospital
8 Recognition of the central and state government for their
employees and health fund schemes.
9 Emergency situations
10 Other patients who have taken treatment earlier
11 Friends and relatives
12 Health insurance schemes
13 Employees of the hospital

III. LEVEL OF SATISFACTION

Tick the following which you feel will be appropriate with the help of the
abbreviations.
HS – Highly satisfied S – Satisfied
JS – Just Satisfied DS – Dissatisfied
HDS – Highly dissatisfied

3.1. a) Level of satisfaction about the registration service

S.No Factors HS S JS DS HDS
1 Reception Service
2 Availability of Information
3 Waiting time for admission
4 Procedure for admission

b) In case of dissatisfied / highly dissatisfied state the reason

3.2 a) Level of satisfaction about the physical competence & medical care
S.No Factors HS S JS DS HDS
1 Professional competence of Doctors
2 Time spent by the doctor for diagnosis
3 Explanation about the health and
Treatment
4 Attitude and Behavior
5 Willingness to listen/answer patient’s
questions
6 Psychological support
7 Health education provided
8 Visit
9 Professional appearance

b) In case of dissatisfied/highly dissatisfied state the reason

3.3 a)Level of satisfaction about the nursing center care

S.No Factors HS S JS DS HDS
1 Nursing skills
2 Attitude and behavior
3 Promptness in meeting needs
4 Mediation at regular intervals is in time
5 Psychological support
6 Professional appearance

b) In case of dissatisfied / highly dissatisfied state the reason

3.4 a) Level of satisfaction about Room Environment

S.No Factors HS S JS DS HDS
1 Calm & Quietness in room
2 Bed size and quality
3 Facilities (Fan, water, sanitation etc)
4 Cleanliness
5 Appearance
6 Ventilation

b) In case of dissatisfied / highly dissatisfied state the reason

3.5. a) Level of satisfaction about dietary services.
S.No Factors HS S JS DS HDS
1 Timeliness of food served
2 Diet
3
4 Taste
5 Temperature of food served
6 containers

b) In case of dissatisfied/highly dissatisfied sate the reasons

3.6 a) Level of satisfaction with regard to discharge process and billing

S.No Factors HS S JS DS HDS
1 Presenting explanation of the bill
2 Discharge instruction
3 Discharge summary
4 Time taken for the patient to leave the
hospital

b) In case of dissatisfied / highly dissatisfied state the reason

3.7. a) Level of Satisfaction about the quality of the supportive staff.

S.No Factors HS S JS DS HDS
1 Skill & Knowledge of the supportive
sataff
2 Promptness in meeting staff needs
3 Care & Concern
4 Appearance

b) In case of dissatisfied / highly dissatisfied state the reasons

3.8. Your option about hospital charges that you are aware of
Tick the following which you feel will be appropriate with the help of
the abbreviations
VH – Very High H – High
N – Normal L – Low
VL – very cow
S.No Charges VH H N L VL
1 Physicians charges
2 Radiology / Lab Charges
3 Registration Charges
4 Medicines
5 Canteen rates
6 Parking charges
7 Nursing Charges
8 Room Charges
9 ICU Charges
10 Dietary Charges

3.9 a) Did you face any problem in the hospital? Yes / No

b) If yes, kindly specify it.

3.10. Give your suggestion to improve the service to patients.

INTERVIEW SCHEDULE FOR OUT PATIENTS

From personal profile to Awareness
I. PERSONAL PEOPLE

1.1. Name and address :

1.2. Age : a) up to 20 years b) 21 – 30 years
c) 31 – 40 years d) 41 – 50 years
e) 51 – 60 years f) 61 years & above

1.3. Sex : a) Male b) Female

1.4. Educational Qualification : a) Illiterate b) Primary Level

c) HSC Level d) Graduation Level
e) Diplomo Level f) Post Graduation Level
g) Professional Level.

1.5. Occupation Status : a) Agriculturist b) Business

c) Employees d) Professional
e) House Wife f) Student
f) Retired Person.

1.6. Monthly Family Income : a) Up to Rs.5,000/- b) Rs.5000 - 10,000/-

b) Rs.10,000 – 15,000/- d) Rs.15,000 – 20,000/-
e) Rs.20,000 – 25,000/- f) Rs.25,000 and above.

1.7. Area of residence : a) Urban b) Rural

1.8. Nature of treatment :

II. AWARNESS :
2.1 a) Are you aware of the following medical and surgical service offered by
the hospital? Yes / No
b) If yes, tick the service that you are aware of

S.No Medical S.No Surgical

1 General 1 General
2 Cancer 2 Cardiac Surgery
3 Cardiology 3 Dental
4 Dermatology 4 ENT
5 Diabetes 5 Gynecology & Obstetrics
6 Gastro Eterology 6 Neuro Surgery
7 Heamatology 7 Orthopedics
8 Nephrology / Urology 8 Ophthalmology
9 Neurology 9 Plastic/Cosmetic Surgery
10 Paediatrics
11 Psychiatry
12 Pulmonology
13 Rheumatology

2.2 a) Are you aware of the supportive services offered by the hospital?
Yes / No
b) If yes, specify the services offered by the hospital which you are
aware of

S.No Service S.No Service

1 Ambulance 7 Laboratory
2 Blood Bank 8 Nursing
3 Canteen 9 Operation Theater
4 Dietary 10 Pharmacy
5 House Keeping 11 Radiology
6 ICU 12 Registration
2.3. a) Are you aware of the following Hospital Charges? Yes / No
b) If yes specify the charges that you are aware of

S.No Charges S.No Charges

1 Physician Charges 5 Canteen rates
2 Radiology / Laboratory 6 Parking Charges
3 Registration 7 Dressing and Injection
4 Medicines

2.4. How did you come to know about this hospital, its service and charges?
a) Advertisement b) Employees of the Hospital
c) Private Practitioners d) Other Patients
e) Share Holders f) Prime Location
g) Health Camps h) Friends and Relatives.

2.5. If through advertisement, which media

a) Newspaper and magazines b) Radio and TV
c) Banners, Posters etc. d) Web

2.6. Reasons for selection of this Hospital

(If more than one factor, rank them)
S.No Reasons for selection Rank
1 Private Physician’s advice
2 Reputation of the Physician concerned in the hospital
3 Reputation of the hospital
4 Nearness of the hospital to the patients residence
5 Lower charges compared to the other hospital
6 Facilities and care available in the hospital
7 Concessions offered by the hospital
8 Recognition of the central and state government for their
employees and health fund schemes.
9 Emergency situations
10 Other patients who have taken treatment earlier
11 Friends and relatives
12 Health insurance schemes
13 Employees of the hospital

III. LEVEL OF SATISFACTION

Tick the following which you feel will be appropriate with the help of
the abbreviations.
HS – Highly satisfied S – Satisfied
JS – Just Satisfied DS – Dissatisfied
HDS – Highly dissatisfied

3.1. a) Level of satisfaction about the registration service

S.No Factors HS S JS DS HDS
1 Reception Service
2 Availability of Information
3 Waiting time for admission
4 Procedure for admission

b) In case of dissatisfied / highly dissatisfied state the reason

3.2 a) Level of satisfaction about the physical competence & medical care
S.No Factors HS S JS DS HDS
1 Professional competence of Doctors
2 Time spent by the doctor for diagnosis
3 Explanation about the health and
Treatment
4 Attitude and Behavior
5 Willingness to listen/answer patient’s
questions
6 Psychological support
7 Health education provided
8 Daily Visit
9 Professional appearance

b) In case of dissatisfied/highly dissatisfied state the reason

3.3 a) Level of satisfaction about outpatient department

S.No Factors HS S JS DS HDS
1 Location of OPD in the hospital
2 Space in the OPD department
3 Facilities (Seating, Fan, Water,
Sanitation etc.
4 Consulting time of OPD department

b) In case of dissatisfied/highly dissatisfied state the reason

3.4. a) Level of Satisfaction about the quality of the supportive staff.

S.No Factors HS S JS DS HDS
1 Skill & Knowledge of the supportive
staff
2 Promptness in meeting staff needs
3 Care & Concern
4 Appearance

b) In case of dissatisfied / highly dissatisfied state the reason.

3.5. Your option about hospital charges that you are aware of
Tick the following which you feel will be appropriate with the help of
the abbreviations
VH – Very High H – High
N – Normal L – Low
 VL – very cow
S.No Charges VH H N L VL
1 Physicians charges
2 Radiology / Lab Charges
3 Registration Charges
4 Medicines
5 Canteen rates
6 Parking charges
7 Dressing and Injection Charges

3.6 a) Did you face any problem in the hospital? Yes / No

b) If yes, kindly specify it.

3.7. Give your suggestions to improve the service to patients.

EXPECTATIONS OF THE PATIENTS

Based on your experience as a patient, pleased think that the kind of

hospital that would deliver high quality of services. Show the extent to
which you think such a hospital would possess the features described by the
each statement with the help of the numbers next to each statement.

If you strongly agree that such hospital should possess a feature tick
the number 7; if you strongly disagree then tick the number 1. If your
feelings are not strong tick the appropriate number in the middle.

Statements 1234567
1. Hospital should have up to date Equipment

2. The physical facilities of the hospital should be visually appearing

3. The hospital staff should be clean and well groomed

4. The appearance of the physical facilities of the hospital should be in

keeping with the type of service provided

5. when hospital promises to do something by a certain time, they should

do so

6. when patient / attendants have a problem the hospital should take

every problem the hospital should take every step to solve it

7. The hospital should be dependable

8. The hospital should provide its services at the time it promises to do so

9. Hospital should keep its records accurately

10.The hospital staff should tell patients / attendants exactly when service

will be performed.

11.The hospital staff should give prompt service to patients / attendants

12.The hospital staff should always be willing to help patients/attendants

13.The hospital staff should not be too busy to respond to patients /

attendants request

14.The hospital staff should always be honest and genuine

15.The patients / attendants should feel safe in their dealings wit the

hospital staff

16.The hospital staff should be consistently courteous with patients/attendants

 17.The hospital staff should have sufficient knowledge to answer the

questions of patients / attendants

18.The hospital should give patients / attendants individual attention

19.The hospital staff should respect patients own value system

20.The hospital should have working hours convenient to all patients /

attendants

21.The hospital staff should understand the needs of their patients /

attendants

PERCEPTIONS OF THE PATIENTS

The following statements relates to your feelings about their hospital.

Please show the extent to which you believe that this hospital possesses the
features described by each statement wit the help of the numbers next to
each statement.

If you strongly agree that such hospitals should posses a feature tick
the number 7; if you strongly disagree then tick the number 11. If your
feelings are not strong tick the appropriate number in the middle.

Statements 1234567
1. Hospital should have up to date Equipment

2. The physical facilities of the hospital should be visually appearing

3. The hospital staff should be clean and well groomed

4. The appearance of the physical facilities of the hospital is in keeping

with the type of services provided

5. The hospital promises to do something by a certain time, it does so

6. When patient / attendants have a problem the hospital takes every step

to solve it.

7. The hospital is dependable

8. The hospital should provides services at the time it promises to do so

9. Hospital should keep its records accurately

10.The hospital staffs should tell you exactly when services will be

performed.

11.The hospital staff give you prompt services

12.The hospital staff are always be willing to help you

13.The hospital staffs are not be too busy to respond to your request.

14.The hospital staffs are always honest and genuine.

15.You feel safe in your dealings with the hospital staff

16.The hospital staffs are consistently courteous with you.

17.The hospital staffs have sufficient knowledge to answer your questions.

18.The hospital staff give you individual attention

19.The hospital has working hours convenient to you

20.The hospital staff respect patients own value system

21.The hospital staff understand your specific needs

THE END