Annexure 1: QUESTIONNAIRE FOR SURVEY

Questionnaire for assessing the level of Patient Satisfaction of indoor and outdoor patients (to be
administered to the inpatients who have been discharged from the hospital, before they leave the
premises, and on outpatients after they have been treated at the OPDs.)

General Information:

1. Name of patient (and who is the respondent)

2. Age

3. Sex

4. Address

5. Date of interview

6. Since when has he been in the hospital (for inpatients)

7. Occupation
a) Farmer  d) Government employee 
b) Professional  e) Other (please specify)____________
c) Businessman 

8. Income level (per month)

a) Less than 5000 
b) 5000-10000 
c) 10000 and above 

9. Type of
i. Patient a) Inpatient  b) Outpatient 
ii. Treatment a) Medical  b) Surgical 

10. Disease or problem

__________________________________________

11. Dept. visited

12. Doctor

13. Tests undertaken:

a. Radio diagnosis 
b. Pathology 

14. Type of Ward/ Room (for inpatients)

a) General 
b) Special 

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 c) Semi-special 
d) Deluxe 
e) ICU
i. MICU 
ii. SICU 
iii. SIMC 
iv. PICU 
v. NICU 
(Specify which department the ward falls under)

15. Policy holder

a) Krupa  b) Non-Krupa 

16. Number of visits to Shree Krishna Hospital in the last 6 months__________

17. Which was the first point of contact when you entered the hospital?
a) Reception counter 
b) Krupa desk 
c) Security Personnel 
d) Registration Counter 
e) Social worker 
f) Other (please specify) 

18.Where did you get your case registered?

a. General counter 
b. Krupa counter 

19. Did you avail of any freeship facilities provided by the hospital?
a) Yes  b) No 
If yes please specify what kind and how much__________________________
_______________________________________________________________

20. Did you find any difficulty regarding the freeship?

a) Yes  b) No 

If yes, please indicate:

a) Access to Freeship 
b) Procedural details 
(ease of obtaining it)
c) Other (if any specify)_______________________________________

21. Have you taken any mediclaim facilities? If yes specify which kind_________
__________________________________________________________________

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22. Rate the following factors on the scale in choosing a hospital.

Extremely Important (5) Very Important (4) Undecided (3)

Somewhat Important (4) Not Important (1)

1) Services Provided 5 4 3 2 1

2) Location 5 4 3 2 1

3) Expert Referrals 5 4 3 2 1

4) Word of mouth 5 4 3 2 1

5) Historical association 5 4 3 2 1

6) Reputation 5 4 3 2 1

7) Value for money 5 4 3 2 1

8) Infrastructure and medical facilities 5 4 3 2 1

9) Convenience 5 4 3 2 1

10) Skill profile of Doctors etc. 5 4 3 2 1

11) Efficacy of service provided 5 4 3 2 1

12) Advertisement 5 4 3 2 1

13) Discount/freeship 5 4 3 2 1

14) Support facilities 5 4 3 2 1

15) Aesthetics 5 4 3 2 1

16) Grievance redressal system 5 4 3 2 1

17) Others specify (if any)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
________________________________________

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Please rate the following:
Completely satisfied (5) Somewhat Satisfied (4) Undecided (3)
Somewhat Dissatisfied (2) Completely Dissatisfied (1)
___________________________________________________________________________
1. Information pertaining to patient’s rating of the hospital as a whole:

1. Location 5 4 3 2 1
2. Infrastructure 5 4 3 2 1
3. Facilities 5 4 3 2 1
4. Technology 5 4 3 2 1
5. Cleanliness of
a. Corridors 5 4 3 2 1
b. Bathrooms 5 4 3 2 1
c. Ward in general 5 4 3 2 1
d. For inpatients: Bedsheets 5 4 3 2 1
(including regularity of changing)
6. Layout (Maternity –Pediatric, 5 4 3 2 1
location of testing depts., (ultrasound-bathroom etc)
7. Comfort of surroundings 5 4 3 2 1
8. Aesthetics (Trees, light, cramping or 5 4 3 2 1
spaciousness of wards/ rooms, colour of wards, rooms)
9. Skill profile of doctors and other 5 4 3 2 1
healthcare professionals
10. Expenses (or costs) 5 4 3 2 1

Where do u find the cost high? If found high in which department or treatment?

Any other comments if any pertaining to Hospital as a whole:

__________________________________________________________________________________
____________________________________________________________________

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2. Information pertaining to patient’s rating of the staff

1. Courtesy shown by:

a. Receptionists/ Registration counter 5 4 3 2 1
b. Personnel
c. Nurses 5 4 3 2 1
d. Doctors 5 4 3 2 1
e. Lab Technicians 5 4 3 2 1
f. Ward Boys 5 4 3 2 1
g. Pharmacy staff 5 4 3 2 1
h. Billing staff 5 4 3 2 1
i. Any other staff that patient mentions5 4 3 2 1
2. Information provided by doctor or 5 4 3 2 1
nurse to the patient
3. Way in which information was provided to
family or attendants of the patient 5 4 3 2 1
4. Attentiveness of nurses to calls from patients 5 4 3 2 1
for help or medical attention
5. Gentleness of nurses in administering 5 4 3 2 1
medical treatment

Any other comments pertaining to staff

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________

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3. Information pertaining to patient’s rating of the services provided
1. Diagnosis by Doctor 5 4 3 2 1
2. Compassion and reassurance by doctor 5 4 3 2 1
3. Patience or attention by Doctor 5 4 3 2 1
4. Personal attention 5 4 3 2 1
5. Consultation with Doctor of choice 5 4 3 2 1
6. Privacy of Consultation 5 4 3 2 1
7. Duration for receiving test results 5 4 3 2 1
8. Kitchen food (inpatients only)
a) Timeliness 5 4 3 2 1
b) Cleanliness 5 4 3 2 1
c) As per Dietician instruction 5 4 3 2 1
9. No. of visits by Doctors (inpatient) 5 4 3 2 1
10. Regularity of ward staff 5 4 3 2 1
11. Availability of Medicine 5 4 3 2 1
12. Information dissemination to relatives 5 4 3 2 1
13. Efficacy of treatment 5 4 3 2 1
14. Facilities for persons accompanying patient 5 4 3 2 1
15. Procedure at the time of discharge 5 4 3 2 1
16. Emergency services (ambulance etc.) 5 4 3 2 1
at trauma center

Any other comments pertaining to services provided

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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__________________________________________________________________________________
__________________________________________________________________________________
_________________________________

4. Information pertaining to procedural details

1. Easy location of the departments 5 4 3 2 1

2. Time spent at
a) Registration 5 4 3 2 1
b) Pharmacy 5 4 3 2 1
c) Cashier 5 4 3 2 1
d) Test (Specified including
receiving report on time) 5 4 3 2 1
e) Consultation with Doctor 5 4 3 2 1
3. Billing promptness 5 4 3 2 1
4. Clarity in showing expenses 5 4 3 2 1
5. No overcrowding 5 4 3 2 1
Any other grievance pertaining to procedural details

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5. Information pertaining to Krupa details

1. Initial information 5 4 3 2 1
2. Discount on medicine 5 4 3 2 1
3. Range of diseases or ailments covered 5 4 3 2 1
4. Price 5 4 3 2 1
5. Range of options 5 4 3 2 1
6. Media approach 5 4 3 2 1
7. Post registration tracking 5 4 3 2 1
8. Documentation 5 4 3 2 1
9. Treatment offered at hospital 5 4 3 2 1
10. Information provided in booklet 5 4 3 2 1
11. Clarification of doubts 5 4 3 2 1
12. Association with other hospitals 5 4 3 2 1
13. Other benefits (such as income tax exemption) 5 4 3 2 1
14. Hospitality shown by Krupa staff 5 4 3 2 1

Q. Would you like to suggest your friends/ relatives/ neighbours to become a member of Krupa? If
yes, why? If no, why?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________

Any Other grievances in general:

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