Questionnaire on Evaluating Patient Perception on Healthcare Industry in Sri Lanka

I am a final year BSc Management student at IIHE and as part of my research project I have selected to
study the perceptions of patients on healthcare received during a recent hospital stay.

I will be grateful if you can spare some time to fill in this questionnaire and give your honest answers
about your recent experience during the hospitalisation. The questionnaire is in parts; one is about some
simple questions about yourself and the other part is about your perception of facilities, services and care
that you have recently able to experience first-hand. The information that you give will be kept
anonymous and confidential and will be used only for the purpose of writing a report as part of my
studies.

Thank You

Nashwa Mohideen

Section ONE – Personal Details

Please tick (√) the most appropriate answer within the given box.

1.1 Please state your gender.

Male x

Female

1.2 Which age category do you belong to?

16-25 26-35 36-45 46-55 56-65 66-75 Over 75

1.3 Where is your usual residence located?

…………………………………………………………………………………………………

Colombo or major town Suburban town Rural

x

1.4 What is your marital status?

Single Married Divorced or Separated

x

1.5 What is the total monthly income range (Rs.)?

Below 20,000 20,000 to 40,000 40,000 to 80,000 80,000 -100,000 Over 100,000

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1.6 What is your occupation?

Not employed Business related /self Managerial / Technical/ clerical Professional

employed Administrative
x

1.7 What is the highest education level that you have attained?

GCE-OL GCE-AL Diploma Graduate Other ( Specify)

x

Section TWO – Information about recent hospitalisation

2.1 When was your recent hospitalisation?

In the last ONE In the last THREE In the last SIX In the last NINE In the last ONE
month months months months year or more
x

2.2 What type of illness did you have at that time?

Sudden unexpected illness Long standing illness Recurring illness

(e.g. : fever) (e.g. : heart or diabetic problem) (e.g. : asthma / wheezing)

2.3 What type of specialist did you consult?

General physician Heart specialist Neurology Diabetic specialist Rheumatologist

General Surgeon Gynaecologist ENT specialist EYE specialist Other

2.4 What type of treatment did you receive while in hospital? (Indicate more than one if relevant)

Only medicines Underwent minor Underwent major Underwent a Had a gadget

surgery surgery procedure inserted
( e.g. : Endoscopy, ( e.g. :Pacemaker,
Colonoscopy) Stent)
x

2.5 Would you like to tell which hospital you visited for treatment?

Nawaloka Durdans Lanka (Apollo) Asiri Other

2.6 What type of room did you occupy?

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 Normal standard Semi-luxury room Luxury room ICU Other
room

2.7 On what basis did you select the hospital?

Doctors Previous personal Friend / Relations Hospital Other

recommendation experience recommendation promotion

Section THREE- Measuring Patient Perception

Section THREE of this questionnaire attempts to find out your experience during the hospital stay. The
questions are also to understand your perception on the nature of service, care and facilities.

Instructions to fill Section THREE:

Please tick (√) the most suitable answer according to your opinion for each of the characteristics given
below.

3.1 Characteristics Regarding Service Very much Below As Better than Much
Quality below expectation expected expected better than
expectation expected

3.1.1 Convenience of location x

3.1.2 Cleanliness and comforts in room x

3.1.3 Friendliness and politeness of nursing x

staff

3.1.4 Professionalism and efficiency of x

nursing staff

3.1.5 Friendliness and politeness of support x

staff

3.1.6 Efficiency of support staff x

3.1.7 Professionalism and competency of x

doctors

Overall perception on service quality x

concerning this hospital

3.2 Characteristics Regarding Very much Below As expected Higher than Much higher
Ethical Aspects below expectation expected than
expectation expected

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3.2.1 Administration fee x

3.2.2 Drug charges x

3.2.3 Operation charges x

3.2.4 Doctors charges x

3.2.5 Overall bill x

3.2.6 Explanation of charges x

Overall perception on ethical x

care concerning this hospital

3.3 Characteristics Regarding Very much Below As expected Better than Much better
Value for Money below expectation expected than
expectation expected

3.3.1 Admission / check-in x

procedure
3.3.2 Parking facilities x

3.3.3 Room facilities (bedding x

quality)
3.3.4 Toilet x

3.3.5 Visitor’s bedding x

3.3.6 Investigations / tests x

3.3.7 Drugs x

3.3.8 Surgery / Procedure x

3.3.9 Food (taste and hygiene) x

Overall perception of value for x

money concerning this hospital

3.4 Characteristics of non-medical Very much Below As expected Better than Much better
care below expectation expected than
expectation expected

3.4.1 Dignity & respect when x

treating patients

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 3.4.2 Promptness of service given to x
the patient

3.4.3 Privacy during treatment x

3.4.4 Treatment of visitors x

Overall perception on non-medical x

care concerning this hospital

3.5 Characteristics of Effectiveness Very much Below As expected Better than Much better
below expectation expected than
expectation expected

3.5.1 Efforts taken to overcome the x

patient’s pain.
3.5.2 Effectiveness of pain relief x

3.5.3Usage of modern medical x

equipment
3.5.4 Educating the patient about x
the possible side effects of the
medicine
3.5.5 Error free and fast retrieval of x
documents
3.5.6 Doctors efforts to makes the x
patient psychologically at ease
Overall perception on x
effectiveness concerning this
hospital

3.6 Characteristics of medical care Very much below As expected Better than Much better
below expectation expected than
expectation expected

3.6.1 Doctor’s knowledge & x

competency

3.6.2 Doctor’s skill level x

3.6.3 Doctor’s willingness to listen to x

patient

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3.6.4 Doctor’s explanation about x
condition

3.6.5 Doctor’s dignity and care towards x

patient

3.6.6 Nurses knowledge & competency x

3.6.7 Nurse’s skill level x

3.6.8 Nurse’s explanation and advices x

Overall perception on medical care x

concerning this hospital

Thank you for taking the time to complete this questionnaire.

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