SAN CARLOS CITY HOSPITAL

HOSPITAL CLIENT EXPERIENCE SURVEY (HCES) FORM

PATIENT’S NAME & SIGNATURE: _____________________________ DATE OF DISCHARGE: ______________

INTERVIEW FACILITATED BY: ________________________ STATION: ____________________
Part I- Triage Staff will facilitate Interview
INSTRUCTIONS: Put a check (✔) mark on the appropriate answers:

The Respondent of this Survey ▢ Patient ▢ Companion ▢ Business ▢ Employee

Form: (Family/Relative)
(visited for business purposes)

Age: ____ Sex: ▢ Female ▢ Male Religion: ▢ Catholic ▢ Muslim ▢ Others (Specify): ______________

▢ Primary ▢ Secondary ▢ Vocational

Educational Attainment:
▢ College ▢ Postgraduate/Masters ▢ No Formal Education

Name of Hospital: __________________________ Date of Consultation/Visit: _________________________

Choose one: ▢ Medical Social Work Department/Malasakit Center

▢ Emergency Room ▢ Information & Admitting Section

▢ Inpatient Services ▢ Cashier/Accounting

Point of Entry Department Visited:
▢ Outpatient Department ▢ Other administrative offices (Specify)

▢ Pharmacy _______________________________________________

Choose one: ▢ Request for Medical Records

▢ Consultation ▢ Request for Psychosocial Assessment/Intervention

▢ Admission ▢ Request for Financial Assistance

Service Availed ▢ Laboratory ▢ Counseling (i.e Nutrition and Dietetics)

▢ Radiology ▢ Other services (Specify)

_______________________________________________
▢ Discharge

▢ Settlement of Fees

Choose one: ▢ 4-6x a year

How frequent do you visit this facility? ▢ First Time ▢ 7-11x a year

▢ 1-3x a year ▢ >12x a year

The Citizen’s Charter is an official document that reflects the services of a government agency/office including its requirements, fees, and processing times among
others.
INSTRUCTIONS: Put a check mark (✔) your answer to the Citizen’s Charter (CC) questions.
CC1 Which of the following best describes your awareness of a CC?
☐ 1. I know what a CC is and I saw this office’s CC.
☐ 2. I know what a CC is but I did NOT see this office’s CC.
☐ 3. I learned of the CC only when I saw this office’s CC.
☐ 4. I do not know what a CC is and I did not see one in this office. (Answer ‘N/A’ on CC2 and CC3)
CC2 If aware of CC (answered 1-3 in CC1), would you say that the CC of this office was …?
☐ 1. Easy to see ☐ 4. Not visible at all
☐ 2. Somewhat easy to see ☐ 5. N/A
☐ 3. Difficult to see
CC3 If aware of CC (answered codes 1-3 in CC1), how much did the CC help you in your transaction?
☐ 1. Helped very much ☐ 3. Did not help
☐ 2. Somewhat helped ☐ 4. N/A

This survey will serve as a basis to help us to improve our services for you to have a better experience in the facility because you are important to us.
Any comments or suggestions you provide through this survey will be highly-appreciated and will be treated with utmost confidentiality.
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 SAN CARLOS CITY HOSPITAL

HOSPITAL CLIENT EXPERIENCE SURVEY (HCES) FORM

Strongly Agree Neither agree Disagree Strongly Not

nor disagree
agree disagree Applicable
INSTRUCTIONS: Put a check mark (✔) on the column that 3
5 4 2 1
best corresponds to your rating for each item

N/A

A. Infrastructures and Process

1. The waiting areas were clean, orderly, and comfortable.

2. The toilets and bathrooms inside the facility were kept clean,
orderly and with a steady water supply.

3. The patients’ rooms were kept clean, tidy, and comfortable.

4. The steps (including payment) I needed to do for my transaction

were easy and simple.(SQD3)

5. The office followed the transaction’s requirements and steps

based on the information provided.(SQD2)

6. I easily found information about my transaction from the office

or its website.(SQD4)

7. I spent a reasonable amount of time for my transaction.(SQD1)

B. Client Engagement and Empowerment

8. The medical condition, procedures and instructions were

discussed clearly.

9. Our sentiments, cultural background, and beliefs were heard and

considered in the treatment procedure.

10. We were given the chance to decide which treatment procedure

shall be performed.

11. I got what I needed from the hospital, or (if denied) denial of
request was sufficiently explained to me.(SQD8)

12. I paid a reasonable amount of fees for my transaction. (SQD5)

***If service was free, mark the ‘N/A’ column)

C. Culture of Responsiveness

13. I was treated courteously by the staff, and (if asked for help) the staff was helpful. (SQD7)

***NOTE: Put a check mark (✔) on N/A if you did not interact with the staff

Doctor

Nurse

Midwife

This survey will serve as a basis to help us to improve our services for you to have a better experience in the facility because you are important to us.
Any comments or suggestions you provide through this survey will be highly-appreciated and will be treated with utmost confidentiality.
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 SAN CARLOS CITY HOSPITAL

HOSPITAL CLIENT EXPERIENCE SURVEY (HCES) FORM

Strongly Agree Neither agree Disagree Strongly Not

nor disagree
agree disagree Applicable
INSTRUCTIONS: Put a check mark (✔) on the column that 3
5 4 2 1
best corresponds to your rating for each item

N/A

Security

Radiology Staff

Pharmacy Staff

Laboratory Staff

Admitting Staff

Medical Records

Billing

Cashier

Social Worker

Food Server

Janitors/ Orderly

14. I was treated fairly, or “walang palakasan”, during my

transaction. (SQD6)

***If online:

I am confident my online transaction was secure.

15. I am satisfied with the service that I availed. (SQD0)

Suggestions on how we can further improve our services (optional) If applicable, please the name of any remarkable hospital staff you would like
to commend, as well as your reason.

Interview Facilitated by: ___________________________ Date _____________

Name & Position

This survey will serve as a basis to help us to improve our services for you to have a better experience in the facility because you are important to us.
Any comments or suggestions you provide through this survey will be highly-appreciated and will be treated with utmost confidentiality.
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 SAN CARLOS CITY HOSPITAL

HOSPITAL CLIENT EXPERIENCE SURVEY (HCES) FORM

– Thank you! –

This survey will serve as a basis to help us to improve our services for you to have a better experience in the facility because you are important to us.
Any comments or suggestions you provide through this survey will be highly-appreciated and will be treated with utmost confidentiality.
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