Patient Satisfaction Survey for Naples Day Surgery Patients

Patient Satisfaction Survey

Dear NDS patient:

Thank you for choosing Naples Day Surgery. It was a privilege to serve you. We trust that our services and individual attention made you as comfortable as possible.

Your responses concerning our service, staff, and facilities are appreciated and allow us to evaluate and improve our performance.

Thank you for taking the time to complete and return this questionnaire.

Sincerely,

Thomas C. Buckley, Executive Director
(239)598-4843

Please select one answer to each of the questions below regarding your experience at Naples Day Surgery.

Scale Definition

Excellent

Very Good

Average

Fair

Poor

PREADMISSION

1. Courtesy and professionalism of our patient representative

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

2. Clarity of Naples Day Surgery’s instructions prior to procedure

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

3. Explanation of our billing procedure with your insurance company

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

4. Explanation of your payment responsibilities

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

DAY OF PROCEDURE

5. Courtesy and professionalism of our admitting representative

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

6. Efficiency of our admission process

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

7. Courtesy and professionalism of our nursing staff

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

8. Family members comfort while at our facility

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

9. Communication between nursing staff and family member

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

10. Actual waiting times as compared with anticipated waiting times indicated by our staff

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

ANESTHESIA

11. Did you meet with a member of the anesthesiology staff before surgery?

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

12. Did he/she answer all your questions satisfactorily?

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

13. Did the anesthesiology staff treat you in a courteous, friendly, and professional manner?

1. Excellent

2. Very Good

3. Average

4. Fair

5. Poor

6. NA

COMMENTS:

HOW COULD WE HAVE IMPROVED OUR SERVICE TO YOU?

14. Would you return to NDS again if you needed to have another procedure?

Yes

15. Would you recommend Naples Day Surgery to your family and friends?

Yes

PATIENT INFORMATION

First Name:

Last Name:

Telephone:

Alternate Phone:

Procedure:

Email:

Physician:

Date of Service:

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