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MINISTRY
OF HEALTH
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SOCIALIST
REPUBLIC OF VIETNAM
Independence - Freedom - Happiness
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No.
3869/QD-BYT
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Hanoi,
August 28, 2019
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DECISION
ON ISSUANCE OF FORMS AND GUIDANCE ON PATIENT AND HEALTH
WORKER SATISFACTION SURVEY
MINISTER OF HEALTH
Pursuant to the Government’s
Decree No. 75/2017/ND-CP dated June 20, 2017 defining the functions, tasks,
entitlements and organizational structure of the Ministry of Health;
Pursuant to the Circular No.
19/2013/TT-BYT dated July 12, 2013 of the Ministry of Health on guidelines for
management of medical examination and treatment quality in hospitals;
At the request of Director
of Department of Medical Examination and Treatment Management affiliated to the
Ministry of Health,
HEREBY DECIDES:
Article
1. Issuing herewith the satisfaction
survey forms, guidance and software as follows:
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b) Form No. 2: Outpatient
survey;
c) Form No. 3: Health worker
survey;
d) Form No. 4: Childbirth
experience at hospital survey;
dd) Form No. 5: Beginning breastfeeding
survey;
e) Guidance on patient and
health worker satisfaction survey;
g) Background information of
hospital registering to conduct survey.
h) Online software to input
data of patient and health worker satisfaction at address http://chatluongbenhvien.vn/.
Article
2. The forms and
guidance on satisfaction surveys apply to both public and private hospitals.
Article
3. Implementation:
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- Act as a contact point to
guide related units to initiate the patient and health worker satisfaction
surveys;
- Inspect and supervise the
units; aggregate, analyze data and send annual reports to the Ministry of
Health on patient and health worker satisfaction indicator.
2. Departments of Health and
health authorities
- Urge and inspect
affiliated hospitals to initiate patient and health worker satisfaction surveys
in accordance with this Decision;
- Aggregate and analyze the
general satisfaction indicator of the units.
3. Public and private
hospitals
- Initiate patient and
health worker satisfaction surveys in an active, regular and scientific manner;
- Input and aggregate data,
results; document, review and analyze unsatisfied comments;
- Promptly resolve claims of
patients and health workers, and then plan and take quality improvement actions
within the competence and resources of the hospitals.
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Article
5. The Chief of the
Ministry Office; Director of Department of Medical Examination and Treatment
Management; Directors of Departments, Heads of relevant units and Mr. (Ms.)
named in Article 1 shall implement this Decision./.
PP.
MINISTER
DEPUTY MINISTER
Nguyen Viet Tien
MINISTRY
OF HEALTH
FORM NO. 1
(SIMPLIFIED)
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In order to improve the
quality of medical examination and treatment, to meet patient satisfaction, the
Ministry of Health and hospitals conduct surveys to find out patients'
aspirations. Your valuable ideas will help the health sector overcome
difficulties and gradually improve the quality to better serve the people. The
Ministry of Health ensures that information is kept confidential and is without
prejudice to the treatment. Thank you very much!
1. Name of hospital: ………………………………………..
2. Fill-in date …………………………
3. Respondent a. Patient
b. Relative
3. Name of department stayed
before discharge ………………..….. 4. Department code (inserted by hospital)………………
PATIENT’S DETAILS
A1. Gender: 1. Male 2.
Female
A2. Age………
A3. Mobile number (required):
A4. Length of hospital
stay ... days
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EVALUATION OF HEALTHCARE
SERVICES
You mark an X on a number from
1 to 5, corresponding to the level of satisfaction or from very poor to
very good for each question below:
is:
is:
is:
is:
is:
Very
dissatisfied
Not
satisfied
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Satisfied
Very
satisfied
or: Very
poor
or: Poor
or: Medium
or: Good
or: Very
good
A. Accessibility
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Diagrams and signs of
directions to departments and wards in the hospital are clear, easy to
understand and easy to find.
A2.
Patient visiting hours are
clearly notified.
A3.
The blocks, stairs, and
patient rooms are clearly numbered and easy to find.
A4.
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A5.
The patient may ask and
call health workers when necessary.
B. The transparency of
information and medical examination and treatment procedures
B1.
The hospital admission
procedures are clear, public and convenient.
B2.
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B3.
Receive clear and complete
explanation about sickness condition, treatment method and expected duration
of treatment.
B4.
Receive clear and complete
explanation and consultation before taking high-tech tests, functional
exploration and techniques.
B5.
Receive public and updated
information about medicine use and treatment costs.
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C. Facilities and
equipment for patients
C1.
The patient's room is
spacious, clean, with adequate temperature control equipment such as fans,
heaters, or air conditioners.
C2.
Adequate hospital beds,
sheets, pillows for each person, safe, secure, in good condition.
C3.
The toilets and bathrooms
are convenient, clean and in good condition.
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C4.
Be assured of safety,
security, order, theft prevention during hospitalization.
C5.
Be provided with adequate,
clean clothes.
C6.
Be provided with enough
hot and cold drinking water.
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Be assured of privacy
during hospitalization such as changing clothes, being examined, toileting in
bed, etc. with curtains, partitions or private beds.
C8.
The hospital canteen
offers adequate and quality meals and essentials.
C9.
The environment in the
hospital campus is green, clean and beautiful.
D. Conduct and
professional capacity of health workers
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Doctors and nurses have
proper words, attitude and communication.
D2.
Service staff (nurses, security
guards, accountants, etc.) has proper words, attitude, and communication.
D3.
Be respected, treated
fairly, cared for and helped by health workers.
D4.
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D5.
Being examined and
encouraged by doctors in the treatment room.
D6.
Be counseled on diet,
exercise, monitoring and prevention of complications.
D7.
Health workers do not
secretly ask for tips.
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E. Performance of services
E1.
Receive adequate and good
quality medicines and instructions for use.
E2.
Medical equipment and
supplies are adequate and modern, and meet your expectations.
E3.
Treatment results meet
your expectations.
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E4.
Your level of trust in the
quality of services.
E5.
Your satisfaction level of
service prices.
G1
Overall, how many
percentage did the hospital meet your expectations before
hospitalization?
(insert the number from 0%
to 100% or you can fill in over 100% if the hospital has good treatment,
exceeding your expectation)
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G2
If there is a need for
examination and treatment of similar disease, will you return or refer
another person to come?
1. Definitely never come
back
2. Don't want to go back
but have few other options
3. Want to transfer to
another hospital
4. Maybe will come back
5. Will definitely return
or recommend to others
6. Others (specify)
……………………………………………………
H
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THANK
YOU VERY MUCH!
MINISTRY
OF HEALTH
FORM NO. 2
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OUTPATIENT SURVEY
In order to improve the
quality of medical examination and treatment, to meet patient satisfaction, the
Ministry of Health and hospitals conduct surveys to find out patients'
aspirations. Your valuable ideas will help the health sector overcome
difficulties and gradually improve the quality to better serve the people. The
Ministry of Health ensures that information is kept confidential and is without
prejudice to the treatment. Thank you very much!
1. Name of hospital: ……………………………………………….
2. Fill-in date …………………………
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A1.
Gender: 1. Male 2. Female
A2
Age: …………………
A3.
Mobile number (required):
A4.
Estimated distance from
residence to hospital: …….km
A5.
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EVALUATION OF HEALTHCARE
SERVICES
You mark an X on a number
from 1 to 5, corresponding to the level of satisfaction or from very
poor to very good for each question below:
is:
is:
is:
is:
is:
Very
dissatisfied
Not
satisfied
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Satisfied
Very
satisfied
or: Very
poor
or: Poor
or: Medium
or: Good
or: Very
good
A. Accessibility
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Diagrams and signs of
directions to the hospital are clear, easy to understand and easy to find.
A2.
Diagrams and signs of
directions to departments and wards in the hospital are clear, easy to
understand and easy to find.
A3.
The blocks, stairs are
clearly numbered and easy to find.
A4.
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A5.
You can find out the
information and register for examination by phone, on the hospital’s website
conveniently.
B. The transparency of
information and medical examination and treatment procedures
B1.
The medical examination
procedures are clear, open and easily understood.
B2.
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B3.
Service prices are clearly
and publicly listed.
B4.
Health workers welcome and
guide patients to do the procedures warmly and enthusiastically.
B5.
Queuing applies to every
procedure: registration, payment, examination, testing, and scan.
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B6.
Evaluate the waiting time
for the registration procedure.
B7.
Evaluate the waiting time
for your examination's turn.
B8.
Evaluate the time spent
with the doctor.
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Evaluate the waiting time
for testing and scan.
B10.
Evaluate the waiting time
for testing and scan results.
C. Facilities and
equipment for patients
C1.
There are clean
examination rooms/lounges, airy and cool in the summer; airtight and warm in
the winter.
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The waiting room has
enough seats for patients that are in good condition.
C3.
The waiting room has
adequate fans (air conditioners), operating regularly.
C4.
The waiting room has
facilities to help the patient feel comfortable such as televisions,
pictures, leaflets, drinking water, etc.
C5.
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C6.
The toilet is convenient,
in good condition, and clean.
C7.
The environment in the
hospital campus is green, clean and beautiful.
C8.
The medical examination
area ensures security, order and theft prevention for people.
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D. Conduct and
professional capacity of health workers
D1.
Health workers (doctors
and nurses) have proper words, attitude and communication.
D2.
Service staff (nurses,
security guards, accountants, etc.) has proper words, attitude, and
communication.
D3.
Be respected, treated
fairly, cared for and helped by health workers.
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D4.
The professional
competence of doctors and nurses meet expectations.
E. Performance of services
E1.
The examination results
meet your expectations.
E2.
Invoices, receipts,
prescriptions and medical examination results are provided fully, clearly,
transparently and explained if there are any questions.
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E3.
Your level of trust in the
quality of services.
E4.
Your satisfaction level of
service prices.
F
Overall, how many
percentage did the hospital meet your expectations before
hospitalization?
(insert the number from 0%
to 100% or you can fill in over 100% if the hospital has good treatment,
exceeding your expectation)
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G
If there is a need for
examination, will you return or refer another person to come?
1. Definitely never come
back
2. Don't want to go back
but have few other options
3. Maybe will come back
4. Will definitely return
or recommend to others
5. Other (specify)………………….
THANK
YOU VERY MUCH!
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FORM NO. 3
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HEALTH WORKER SURVEY
In order to improve the
quality of medical examination and treatment and improve the working
environment of health workers, the Ministry of Health and the hospital conduct
a survey to find out expectations of health workers. The Ministry of Health
ensures information confidentiality We hope you can answer fully, objectively
and accurately. Thank you very much!
1. Name of hospital: …………………………………………………..
2. Fill-in date …………………………
DETAILS OF RESPONDENT
A1.
Gender: 1. Male 2.
Female
A2.
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A3.
Major:
1. Doctor
2. Pharmacist
3. Nurse, midwife
4. Technician
5. Other (specify) ...
A4.
Your highest degree:
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2. College
3. University
4. MA, specialist I
5. Doctor, specialist II
6. Other (specify) ...
A5.
Years of experience in the
medical sector: …………….
A6.
Years of experience at
current hospital: ……………
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Current position:
1. Hospital leader
2. Manager of department/room/center
3. Deputy manager of
department/room
4. Regular/long-term staff
5. Short-term staff.
6. Other (specify) ...
A8.
Scope of specialty:
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2. Subclinical
3. Internal medicine
4. Surgery
5. Obstetrics
6. Pediatrics
7. Infectious diseases
8. Specialties
(ophthalmology, otorhinolaryngology, odonto-stomatology, etc.)
9. Departments not related
to medical examination and treatment
10. Pharmacy
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12. Other (specify) ...
A9.
Are you assigned to
multiple jobs?
1. Not
2. Responsible for 2 jobs
3. Responsible for 3 jobs
or more
A10.
On average, how many times
per month are you on duty? ………. times
YOUR SATISFACTION WITH
HOSPITAL
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is:
is:
is:
is:
is:
Very
dissatisfied
Not
satisfied
Normal
Satisfied
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or: Very
poor
or: Poor
or: Medium
or: Good
or: Very
good
A. Working environment
satisfaction @@@
A1.
The office is spacious,
clean and airy.
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A2.
Adequate office equipment,
desks and chairs ..., old and outdated equipment will be replaced promptly.
A3.
There is a duty room for
health workers.
A4.
Divide time on duty and
work overtime reasonably.
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Protective equipment for
health workers (clothing, masks, gloves ..) is adequate, not old, crumpled,
and not restricted in use.
A6.
The learning environment
enables the health workers to update their knowledge, improve their skills:
library, reading room, information search, internet access, etc.
A7.
Safe working environment
for health workers.
A8.
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A9.
The patients and family
members respect and cooperate with the health worker in the treatment
process.
B. Satisfaction with
supervisors and co-workers
B1.
The supervisors are
capable of handling, administering and solving work effectively.
B2.
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B3.
The supervisors care,
respect and treat health workers equally.
B4.
The supervisors listen to
and receive comments and suggestions from health workers.
B5.
The supervisors encourage
employees when they successfully complete their tasks and make progress at
work.
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B6.
Co-workers are active in
teamwork to fulfill common tasks.
B7.
Friendly and solidary work
environment.
B8.
Co-workers share
experience and support each other at work.
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Co-workers care and
support each other in life.
C. Satisfaction with
internal regulations, wages, benefits
C1.
The hospital's internal
working regulations and rules are clear, realistic and public.
C2.
Working environment in
departments/rooms and in the hospital is democratic.
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The internal spending
regulations are fair, reasonable and public.
C4.
The distribution of the
welfare fund is fair and public.
C5.
Salaries are commensurate
with ability and dedication.
C6.
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C7.
Bonuses and income raise are
commensurate with dedication.
C8.
The distribution of income
raise is fair and encourages employees to work actively.
C9.
Ensure the full payment of
social insurance and health insurance, periodical health checkups and
adequate forms of sickness and maternity support.
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C10.
Adequate sightseeing and
leisure travel.
C11.
Positive movement of
sports and art.
C12.
The hospital union is
active.
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D1.
The workload is assigned
appropriately.
D2.
The professional work
meets your expectations.
D3.
The hospital enables
health workers to improve their professional skills.
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The hospital enables
health workers to continue higher studies.
D5.
Publish standards for
leadership positions.
D6.
Appointment of leadership
positions in democracy and justice.
D7.
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E. General satisfaction
with the hospital
E1.
Be proud to be working at
the hospital.
E2.
Achieve personal success
while working at the hospital.
E3.
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E4.
Will work in the current
department and ward for a long time.
E5.
Will work at the hospital
for a long time.
E6.
Overall satisfaction with
the hospital leadership.
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E7.
Self-assessment of work
performance level at the hospital.
G. Do you have any other
comments or suggestions to the Ministry of Health and hospital leaders?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
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Thank you for taking the
time to complete this survey!
MINISTRY
OF HEALTH
FORM NO. 4
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CHILDBIRTH EXPERIENCE AT HOSPITAL SURVEY
In order to improve the
quality of medical examination and treatment, to meet the satisfaction of
mothers giving birth at the hospital, the Ministry of Health and the hospital
conduct a survey to find out about mothers' experiences in the process of
giving birth. Your valuable ideas will help the health sector improve better
quality. The Ministry of Health ensures that personal information is kept
confidential. Thank you very much!
1. Name of hospital: ………………………………….
2. Fill-in date …………………………
3. Name of departments
stayed ………………..….. (fill in all departments if any)
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4. Department code (inserted
by hospital)………………
5. Mother's identification
number …………………… (inserted in by the mother herself if the code is provided by
the hospital or inserted later by health workers).
PATIENT’S DETAILS
A1.
Age
A2. Mobile phone number:
A3.
Length of hospital stay
... days
A4. This was the….visit
[ordinal number] to the hospital
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Did you use your health
insurance card for this treatment?
1. Yes 2. No
A6.
Birth delivery method? 1. Vaginal
delivery 2. Emergency C-Section
3. Planned C-Section 4.
Other (specify)
A7
During this pregnancy, did
you go to the hospital for prenatal check-ups? If yes, how many times?
1. Number of prenatal care
visits …….
2. Come for labor, no
examination
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EVALUATION OF HEALTHCARE
SERVICES
Please choose a box
from 1 to 5, which corresponds to a very poor to very good satisfaction
level for each of the following questions:
is:
is:
is:
is:
is:
Very
dissatisfied
Not
satisfied
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Satisfied
Very
satisfied
or: Very
poor
or: Poor
or: Medium
or: Good
or: Very
good
A. Accessibility
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Diagrams and signs of
directions to departments and wards are clear, easy to understand and easy to
find.
A2.
Can call and ask health workers
when needed (even outside office hours).
B. Examination and
admission process
B1.
The process of
examination, testing and admission is easy and convenient.
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Waiting time for
procedures and services is acceptable.
C. Providing information,
communication and advices
C1.
Be provided with
information for prenatal testing, ultrasound ...prior to labor.
C2.
Be informed and advised
about the birth process and the risks of complications that may occur.
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Be communicated and
advised to detect danger signs, take care of babies, nutrition regime and
breastfeeding.
D. Facilities and
equipment for patients
D1.
Bed with mattress for
mother and baby is safe, not a shared bed.
D2.
Adequate and clean blankets,
sheets, pillows, gowns, and diapers for mother and baby.
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Toilets and bathrooms are
clean, with adequate paper, soap, and water.
D4.
Patient’s room is well
ventilated, clean, equipped with fans, heaters or air conditioners.
D5.
Be assured of privacy when
changing clothes, being examined and cared at the bed such as with curtains,
mobile partitions or in a private room.
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E. Conduct of health workers
E1.
Doctors have proper words,
attitude and communication.
E2.
Nurses and midwives have
proper words, attitude and communication.
E3.
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E4.
Health workers suggest
tips? (if yes, choose 1; if not, choose 5)
G. The professional
capacity of health workers
G1
The doctor has good
expertise and examination skills.
G2
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G3
Doctors, nurses and
midwives cooperate well and handle work fluently and promptly.
H. Hospitalization results
H1
Safe delivery, good
treatment and care.
H2
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H3
Service prices are
appropriate and commensurate with the money spent.
K1
Overall, how many
percentage did the hospital meet your expectations before
hospitalization? (insert the number from 0% to 100% or you can fill in
over 100% if the hospital has good treatment, exceeding your expectation)
………..%
K2
In your next labor (if
any), would you come back or introduce another person?
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2. Don't want to go back
but have few other options
4. Maybe will come back
5. Will definitely return
or recommend to others
6. Other (specify)………………….
K3
Do you have any other
comments during the birth process at the hospital?
(Clearly state any
compliments or criticisms, comments or suggestions for the hospital and the
Ministry of Health)
THANK
YOU VERY MUCH AND WISH YOU SPEEDY RECOVERY AND HEALTHY BABY
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MINISTRY
OF HEALTH
FORM NO. 5
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BEGINNING BREASTFEEDING SURVEY
1. Name of hospital: …………………………………………………..
2. Fill-in date …………………………
3. Name of department stayed
………………..….. 4. Department code (inserted by hospital)………………
5. Patient’s identification
number (assigned by hospital)……………………………..
PATIENT’S DETAILS
A1. Age
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A3. This is the….visit
[ordinal number] to the hospital
A4. I was hospitalized for
….. days
A5. This is the …..
delivery [ordinal number]
A6. Your birth delivery
method: vaginal delivery or C-Section…..
A7. Your baby’s date of
birth
BREASTFEEDING PRACTICES
B1.
Have you seen
"Regulation on breastfeeding practices" at the hospital? If so,
where? (check multiple numbers if appropriate)
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2. Labor room
3. Postpartum room/ward
4. Consultation room
5. Other (specify)………………….
6. Not seen
B2.
Have you seen pictures and
leaflets on breastfeeding at the hospital? If so, where? (check multiple
numbers if appropriate)
1. Department of
examination
2. Labor room
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4. Patient room
5. Counseling room
6. Other (specify)………………….
7. Not seen
B3.
Did you get breastfeeding
counseling from the hospital? If so, when? (check multiple numbers if
appropriate)
1. The hospital does not
counsel
2. Counseling when taking
antenatal care in hospital
3. Antenatal counseling
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5. Other time
(specify)………………….
B4.
The reason why you were
not counseled by the hospital?
1. I did not take
antenatal care at the hospital
2. I experienced emergency
delivery
3. The health workers
skipped the counseling
4. Other (specify)………………….
5. I were counseled
B5
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1. The hospital did not
counsel
2. I have been counseled
but do not understand
3. I have understood but
not remember what to do
4. I have understood and
remember what to do
5. I have understood
thoroughly the meaning of breastfeeding
6. Other (specify)………………….
…………………………………………………………..
B6.
How long (estimated
minutes) did you receive “cut umbilical cord” after birth?
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2. Delayed umbilical cord
cut: estimated minutes….
3. Don’t remember, don’t
know the number of minutes
4. Other (specify)………………….
………………………………………………………….
B7.
After birth, did you and
your baby experience “skin to skin” contact? If yes, how long?
1a. Get done "skin to
skin" contact
1b. Estimated "skin
to skin" contact in….minutes
2a. Not experienced
"skin to skin" contact
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…………………………………………………………..
B8.
How many minutes has
passed since your baby was first breastfed (estimated minutes if you
remember)
Specify the number
of minutes if you remember: …… minutes
1. Fed immediately after
birth
2. Without 30 minutes
3. Within 1 hour
4. Within 2 hours
5. From 2 hours to 24
hours
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7. Mother did not produce
milk, so the baby had to be fed formula
8. Other (specify)………………….
B9.
Did you receive any
support in breastfeeding practices? If yes who was it? (check multiple
numbers if appropriate)
1. Midwives, nurses
2. Doctors
3. Relatives
4. Other (specify)………………….
5. None
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If yes, how did you get
support in breastfeeding practices? (check multiple numbers if
appropriate)
1. Directly guide the
mother to breastfeed properly
2. Breast massage
3. Milking practices (hand
expression or pumping)
4. Milk duct unclogging
5. Other (specify)………………….
B11.
During the time in the
hospital, did you feed your baby any other food? If yes, what is it (eg
honey, lemon, salt, powder, medicine, etc.)?
1. Exclusive breastfeeding
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3. Ask/buy breast milk
from other mothers
4. Feed formula
5. Feed other food
6. Feed restorative,
functional foods
7. Give medicine to treat
disease
B12.
Did any health worker
recommend buying formula for your baby?
1. Yes
2. No
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In your opinion, what are
the benefits of breastfeeding?
Clearly state the
benefits:
……………………………………………………………
……………………………………………………………
B14.
In your opinion, the baby
needs to be exclusively breastfed for at least how many months and for how
long?
1. At least ……… months
2. Lasts for …… .. months
B15.
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Clearly write
recommendations …………………………… ..
…………………………………………………......
………………………………………………………
THANK YOU VERY MUCH AND WISH
YOU SPEEDY RECOVERY AND HEALTHY BABY! THE END.
PART C. BREASTFEEDING PRACTICES FOLLOW-UP QUESTIONNAIRE
(optional)
The breastfeeding practices
follow-up questionnaire will provide valuable information, helping the hospital
and the Ministry of Health improve the quality of breastfeeding practices, and
improve the quality of the population and children’s health.
Method: the hospital will
assign the survey staff to call the mother once a week and fill out information
on online software from the date on which the baby was discharged until the
baby reaches 6 months old.
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Mother's mobile phone
number:
C2. Interview call date:
C3.
Call in the…week [ordinal
number] after birth
The…week [ordinal number]
C4.
During the past 1 week,
other than breast milk, did you feed the baby other food? If yes, what is it
(eg honey, lemon, salt, powder, medicine, etc.)?
1. Exclusive breastfeeding
2. Feed water
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4. Feed formula
5. Feed other food
6. Exclusive eating, other
than breast milk
7. Give medicine to treat
disease
8. Feed restorative,
functional foods
9. Other (specify) ...
C5.
What are the reasons for
feeding other foods other than breast milk?
1. Due to insufficient
breast milk
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3. Because the baby is
sick
3. Other (specify)………………….
C6.
How does your baby’s
height and weight compare to Child Growth Chart?
1. -1SD
2. -2SD
3. Standard
4. +1SD
5. +2SD
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GUIDANCE ON PATIENT, MOTHER AND HEALTH WORKER SATISFACTION
SURVEY IN FORM NO. 1, 2, 3, 4, 5
(Apply
to state-owned and private hospitals that conduct satisfaction surveys
themselves and inspectorates evaluating hospital quality at the end of the year
(hereinafter referred to as inspectorates) or on ad-hoc basis)
(Appendix
issued with the Minister of Health's Decision No. 3869/QD-BYT dated August 28,
2019)
1. RESPONSENTS
OF SATISFACTION SURVEYS AND FORMS APPLIED
Hospitals, health facilities
with hospital beds for inpatients (not applicable to district health centers
with a preventive medicine function, regional health stations, polyclinics)
shall conduct surveys for the following entities:
- Inpatients: form No.1;
- Mothers giving birth at
the hospital: form No. 1, form No. 5;
- People seeking examination
at the hospital, outpatients: form No.2;
- Health workers, management
positions, leaders of departments/wards, members of the hospital board of
directors: form No. 3.
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Top blank boxes: be filled
with reference number, filled out by the survey staff in accordance with
regulations of the Ministry of Health and hospital regulations. Correct reference
number will help regulatory bodies in statistics, archiving and checking,
monitoring of satisfaction surveys.
The reference numbers shall
be filled in as follows:
The first 5-digit is
hospital code issued by the Ministry of Health, in which the first 2-digit is
the province code, the 3rd digit is the referral level/type of the
hospital and the 4th and 5th digit is number order of the
hospital. The next 5-digit is the code self-designated by the hospital in
conformity with its particulars (for example, the 6th digit is the
code of survey time in the quarter or the year; the 7th digit is the
code of surveyor or code of patient, the 8th, 9th, and 10th
digit is the number order of survey). Hospitals need to have written
regulations on the numbering 6th to 10th digits to ensure that the
numbering is uniformly applied, convenient to manage and search information
when necessary. The numbering is done simultaneously on paper and electronic
forms on the online software.
Survey staff, patients,
health workers will fill in the following ways:
- Fill in the blanks that
require filling;
- Circle the numbers 1 to 5
of the satisfaction questions;
- Circle the number order of
answers to the multiple choice questions;
- Other questions related to
opinions: the patient, the mother and the health worker give answers with
unlimited length.
3. PATIENT
SATISFACTION SURVEYS CONDUCTED BY HOSPITALS
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Identify domains of
patients’ dissatisfaction with their examination and treatment at the hospital
to improve quality, step by step serve patients better, and meet patient
satisfaction and expectations.
3.2. Requirements
1. Ensure science,
objectivity and honesty when conducting surveys.
2. Identify domains of
patients’ dissatisfaction.
3. Compare the satisfaction
levels between varied patients, treated in different departments.
4. Use survey results to
carry out hospital quality improvement.
5. Keep continuous
monitoring of patient satisfaction to continuously improve quality.
3.3. Survey method self-conducted
by hospitals
3.3.1. Survey design: Cross-sectional
study.
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3.3.3. Survey time: Depending
on the size of the hospital, the patient satisfaction survey team can choose a
survey time as follows:
- In 1 or 2 days a week
(except Saturday and Sunday).
- In 1 week, 2 weeks or in 1
month (until full survey sample size upon request).
3.3.4. Sample size
3.3.4.1. For
inpatient/mother survey:
1. For hospitals with more
than 3000 inpatients/mothers per day, apply the formula for calculating the
sample size for cross-sectional study, at least 300 people for each survey.
2. For hospitals from 1000
to 2999 inpatients/mothers per day, apply the formula for calculating the
sample size for cross-sectional study, at least 200 people for each survey.
3. For hospitals under 1000
inpatients/mothers per day, at least 100 people for each survey.
4. For hospitals under 100
inpatients/mothers per month, all inpatients/ mothers will be surveyed within 1
month.
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6. The mother giving birth
at the hospital can be interviewed in both forms 4 and 5 or one form, depending
on the mother's health condition and willingness to cooperate.
3.3.4.2. For the survey of
visitors and outpatients (hereinafter referred to as outpatients)
Outpatient sampling applies
based on the average number of outpatient visits per day.
1. For hospitals with more
than 5000 visits per day: At least 300 outpatients for 1 survey.
2. For hospitals from 500 to
4999 visits per day: At least 200 outpatients for 1 survey.
3. For hospitals from 100 to
499 visits per day: At least 100 outpatients for 1 survey.
4. For hospitals under 100
visits per day: Survey all outpatients in 2 days a week (except Saturday and
Sunday).
3.3.5. Sampling method
3.3.5.1. For inpatient
survey:
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1. For hospitals with more
than 1000 outpatients per day:
In each survey, select at
least 3 clinical departments, including 1 department with high bed occupancy
rate, 1 department with medium bed occupancy rate and 1 department with low bed
occupancy rate. In following surveys, select other departments one after
another. If the hospital has a service or on-demand treatment department, it
will be selected for the survey as the same as other departments.
In each department, choose
the patients according to the following method:
Get a list of patients being
treated (either by software or by number). In each survey, select 1 or more
letters from A, B, C ... to X, Y.
Select the patient according
to the first letter of their first name. In a day, you can choose 1, 2, 3 ...
letters depending on the number of patients being treated, but make sure all
patients with the same first letter of first name are included in the list. For
example, in one day of surveying to choose letter H, we need to ensure that all
patients named Ha, Hanh, Huong, Huy, Han, Hoan, Hoa, Hung, Hoang ... are
included in the list.
In the list, choose the
patient who is going to be discharged from hospital for interview; exclude
patients who cannot answer or inpatients with insufficient information to
answer.
Conduct a survey with the
required number of patients (300 or 200).
2. For hospitals with less
than 1000 inpatients per day, select similar samples until 1000 patients are
reached.
3. For hospitals with fewer
than 100 inpatients per month, choose samples of all inpatients within 1 month
or until 100 forms are reached, whichever comes first.
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The hospital should have a
satisfaction survey book or software, which contains information such as
planning, time of conducting surveys, names of departments to be surveyed and
names of letters to be selected in each survey , persons in charge ... Letters
selected for survey are from A, B, C ... to X, Y respectively.
After each survey is done,
the hospital should record information related to the survey, such as letters
chosen, number of actual respondents, difficulties and problems arising, etc.
It is critical to select the
sample according to the first letter of the patient's first name. Hospitals
need to comply with the single sampling method to ensure randomness and
science.
3.3.5.2. For outpatient
survey:
Based on the capacity,
resources, facilities, location of outpatient department and the actual
situation of the outpatient, the hospital will develop its own sampling plan
for the most suitable and optimal as possible within the hospital conditions
(eg the survey can be conducted for multiple days in a week and multiple weeks in
a year). However, all sampling plans should ensure two important principles:
1. Make sure the sample
selection is random.
2. Make sure the collected
information is objective and truthful.
To select random samples,
the hospital can randomly select the patient according to the number of
registration forms, based on the average number of visits per day to choose the
k coefficient accordingly.
For example, if the hospital
has 1000 visits per day, the number of survey forms per day is 100, so the
coefficient k = 10. The survey team select samples 10 persons apart from each
other, taking all patients whose registration form’s number ends with number 1,
for example 11, 21, 31, 41 ...
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The coefficient k is
determined by the hospital, but it is important to ensure that the selected
outpatients include first persons to last persons who register for examination
in a day because the satisfaction levels vary from the early registrants to
late registrants.
Hospitals may develop
alternative sampling plans on their own, but should ensure randomness and
representation when selecting respondents. Hospitals must have a written
regulation if they have a separate sampling plan other than the plan specified
in this guidance.
If the outpatient fills in
the form by himself/herself, the hospital can give the form to the patient
concurrently with time when the examination number is issued. Before leaving
the hospital, the patient should return the form to the surveyor or put it in
the suggestion box.
If the hospital conducts the
oral interview with the patient: after the patient receives medicines at the
pharmacy, or if the patient does not buy medicines, after the outpatient
completes the entire examination process and before leaving.
3.3.6. Investigator,
surveyor
Human resources performing
the satisfaction survey include the following:
1. Quality control staff and
quality control network members (not wearing healthcare uniforms or badges
during the interview);
2. Staff of the social work
department, customer care;
3. Professional
investigators and surveyors who are contracted with the hospital;
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5. Volunteers;
6. Patients who fill out the
form by themselves (after detailed instructions).
4. PATIENT
SATISFACTION SURVEY CONDUCTED BY INSPECTORATES OF MANAGING AGENCIES
4.1. Survey design: Cross-sectional
study.
4.2. Survey cycle: at
least once a year at the end-of-year hospital inspection and assessment (and
mid-year if the management authority does it).
4.3. Survey time: Based
on the size of the hospital, the actual situation and decision of the chief
inspector; the patient satisfaction survey team can choose a survey time as
follows:
1. Differ from the time when
the inspectorate comes to the hospital (for example the survey will be
conducted 1, 2, 3 days or 1 or 2 weeks in advance, or appointing surveyors
independently from the inspectorate and provide results to the inspectorate).
2. Coincide with the time
when the inspectorate comes to the hospital.
Notes: Inspectorates are
recommended to choose option 1 to do the survey.
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4.4.1. For inpatient survey:
1. For hospitals with more
than 30 inpatients per day: survey at least 30 inpatients.
2. For hospitals with less
than 30 inpatients per day, survey all inpatients that have been and are being
treated for 3 days or more.
4.4.2. For outpatient
survey:
Survey at least 30
outpatients.
Notes: In
case the inspectorate has difficulties, limited time and staff, poor
interviewing skills, etc. that prevents it from collecting enough 30 patients;
the inspectorate can reduce the number of inpatients and outpatients to be
surveyed. The chief inspector and secretary shall decide the number of patients
but not fewer than 10 inpatients and 10 outpatients, and should specify the
reason for not collecting enough 30 survey forms in the minutes and reports.
4.5. Sampling method
4.5.1. For inpatient survey:
To ensure randomness and
representation, and to help the hospital identify domains of patients’
dissatisfaction, the inpatient sample selection is as follows:
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Select at least 3 clinical
departments, including 1 department with high bed occupancy rate, 1 department
with medium bed occupancy rate and 1 department with low bed occupancy rate.
In each department, choose
the patients according to the following method:
- Get a list of patients
(either by software or by number).
- Select the patient according
to the first letter of their first name. In a day, you can choose 1, 2, 3 ...
letters depending on the number of patients being treated, but make sure all
patients with the same first letter of first name are included in the list. For
example, in one day of surveying to choose letter H, we need to ensure that all
patients named Ha, Hanh, Han, Hoan, Huy, Huong, Hoa, Hung, Hoang ... are
included in the list.
- In the list, choose the
patient who is going to be discharged from hospital for interview; exclude
patients who cannot answer or inpatients with insufficient information to
answer.
- Survey enough 30 patients,
probably survey 10 inpatients in each department. If the number of patients in
the three selected departments is not enough 30 people, continue to choose
other departments until the sample size reaches 30 people.
2. For hospitals with less
than 1000 inpatients per day, select similar samples in varied departments
until 10 patients are reached.
3. For hospitals with less
than 30 inpatients per day, select samples of all inpatients that are going to
be discharged.
4.5.2. For outpatient
survey:
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5. ANALYSIS
OF SATISFACTION SURVEY DATA
5.1. Satisfaction score
calculation (general application for respondents)
- The response options of
patients from 1 to 5 in the satisfaction survey questions are scored from 1 to
5, respectively.
- Overall average
satisfaction score is equal to the average score of all survey forms (compared
with the maximum score of 5).
- Formula for calculating
average satisfaction score:
Numerator = [(Total score of
all satisfaction survey questions of the 1st respondent)/(Total number of
questions)] + [(Total score of all satisfaction survey questions of the 2nd
respondent)/(Total Number of Questions)] + [(Total score of all satisfaction
survey questions of the nth respondent)/(Total number of questions)].
Denominator = Total number
of respondents.
- The average score of each
aspect is equal to the average score of the questions in each aspect of all
survey forms (compared with the maximum score of 5).
5.2. Satisfaction score
calculation (general application for respondents)
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+ Numerator = {[(Total
number of questions with level 4 answer + Total number of questions with level
5 of the 1st respondent)/(Total number of questions)] + [(Total number of
questions with level 4 answer + Total number of questions with level 5 answer
of the 2nd respondent)/(Total number of questions)] + [(Total number of
questions with level 4 answer + Total number of questions with level 5 of the
nth respondent)/( Total number of questions)]} x 100.
Denominator = Total number
of respondents.
- Satisfaction rate for each
aspect: apply the same calculation method.
5.3. Comprehensive
satisfaction indicator
Calculation of comprehensive
satisfaction indicator:
+ Numerator = {(The 1st
respondent with all answers at level 4 or 5) + (the 2nd respondent with all
answers at level 4 or 5) + (the nth respondent with all answers at level 4 or
5)} x 100
(The numerator excludes
those who answered any of the levels 1, 2, 3);
+ Denominator = Total number
of respondents.
5.4. Response rate compared
to expectation
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Hospitals may add other
indicators developed and regulated by themselves.
6. DATA
IMPORT, REPORT WRITING AND RESULTS DISCLOSURE
6.1. Data import
The hospital and the
inspectorate can choose one from the following:
1. Interview and fill out
information on paper forms, then input data into computer using office software
(eg excel, epidata), and then analyze data.
2. Interview and fill out
information on online software in phones, tablets, desktop computers. The
software will automatically analyze and extract results for hospitals and
inspectorates as required.
6.2. Hospitals writing
reports
The hospital will extract
the results on the online software, extract the data and deep dive in other
aspects (if there is someone to analyze the data). Hospitals can compare
patient’s satisfaction rates and feedbacks between clinical departments, and
then write reports. The report must identify main issues that make the patient
unsatisfied and appendices of detailed comments of the patients. Based on the
findings from the survey, the hospital will make a list of priority issues for
quality improvement.
6.3. Inspectorates writing
reports
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The patient satisfaction
survey results of the survey team should be compared with the self-survey
results of the hospital.
Patient satisfaction survey
results of the survey team are published along with the assessment results
according to the Hospital Quality Criteria Set.
If the results of the survey
on satisfaction rate are very high, inconsistent with the results of the
quality assessment: the inspectorate will not publish the results of the
satisfaction indicator, just publish noteworthy patient opinions and findings
in the survey. The inspectorate needs to have lessons learned, review if the
method and the survey process has been initiated in an objective, honest, scientific
manner, etc. according to the instructions. For example, if the inspectorate
only conduct the satisfaction survey on the day to check and evaluate the
hospital quality, the satisfaction rate would have errors due to the influence of
many reasons and impacts.
Notes: The comprehensive
satisfaction indicator is an index that has been included in the satisfaction
survey operation of the Ministry of Health since 2019 according to this
Decision to monitor quality improvement, hospitals and inspectorates of management
authorities are not required to publish it.
7. HEALTH
WORKER SATISFACTION SURVEYS
7.1. Health worker
satisfaction survey conducted by hospital0}
The hospital will survey the
satisfaction of health workers in a scientific, objective, and honest manner,
without names of respondents and their details are kept confidential.
The hospital will conduct a
self-survey in the form of sampling of all leaders, managers, and staff of the
hospital or each department in turn.
The survey and filling out
are done by entering data directly on the online software or filling in paper
forms. The survey team uses the boxes for the health workers to put completed
survey forms in.
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The analyzing methods and
writing reports on health workers satisfaction are similar to the patient
satisfaction survey guide.
The survey team will extract
results on online software or supplement other data analysis methods.
Notes:
The survey team of health worker
satisfaction survey is responsible for ensuring 100% confidentiality of the
respondent’s information, even if the Board of Directors requests related
information to find the respondent.
If the hospital conducts a
"health worker satisfaction survey" in the circumstance that health
workers and department leaders are "afraid" of secret disclosure or
may be victimized for give dissatisfaction answers, the team assigned to survey
health workers satisfaction is not required to conduct a survey, but it is
necessary to specify the reason: "the survey cannot be done due to the
hospital's lack of internal democracy".
7.2. Health worker
satisfaction survey conducted by inspectorate
The inspectorate of the management
authority shall inspect the health worker satisfaction survey conducted by the
hospital during the year on online software and check books, records, reports,
etc. thereof.
The survey by the
inspectorate is conducted as follows:
- Randomly select health workers
representing departments:
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+ Select health workers
representing doctors, pharmacists, nurses, technicians, and management
positions;
- Choose a sample size of at
least 30 people.
The inspectorate conducts
the survey using the following 3 methods: (members choose the appropriate
method):
1. Instruct health workers
to fill in the online software by themselves (pre-login with the authority’s
survey account);
2. Hand out the survey forms
to the health workers to fill out, schedule a time and collect the survey
forms;
3. Interview the health
workers in person at a separate space, location and no other hospital staff
participates in the interview, then enter the data on the online software.
Notes:
The inspectorate of
management authority that conducts the health worker satisfaction survey is
responsible for ensuring 100% confidentiality of the respondent’s information,
even if the Board of Directors requests related information to find the
respondent.
If the inspectorate does not
have enough skills to conduct an objective, democratic, scientific survey of
health worker satisfaction and there is a risk of not keeping the health workers’
information confidential, the inspectorate will not conduct a survey and record
it in the hospital quality inspection and assessment record.
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8.1. Departments of Health,
health authorities of Ministries and branches
Every Department of Health
is provided with a username and password for the satisfaction survey conducted
by the management authority.
The account of the
Department of Health can view the surveys of all affiliated hospitals but
cannot change the information.
8.2. Hospitals
Each hospital is provided
with a hospital code to enter the survey form and is provided with a username and
password.
For newly established
hospitals, the Department of Health shall fill out the hospital's information
according to the application form and send it to the Department of Medical
Examination and Treatment in writing or by email at: [email protected]
hospital will insert the information by itself according to the application
form for satisfaction survey account on the online software.
If any information changes,
for example, the hospital name, size, and contact point in charge; it will
update it on the online software.
Notes:
In the process of conducting
the patient and health worker satisfaction survey and, if the hospital or the
inspectorate encounters difficulties and problems; please contact the
Department of Medical Examination and Treatment, Department of Quality Control
and the Line Direction for further answers.
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9.1. Details of Department
of Health
1. Name of Department of
Health:
2. Filled in by: [name]
3. Position:
4. Cell phone number:
5. Email address to send
account:
9.2. Details of hospital
1. Name of hospital (clearly
and fully state hospital, institute or medical center):
2. Hospital code issued by
the Ministry of Health/Department of Health to perform medical examination and
treatment with health insurance:
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4. Rank:
5. Type of hospital* (choose
from 1 to 9 according to the instructions below)
6. Number of beds according
to the assigned or approved plan:
7. Actual number of beds
(according to the hospital's statistic data before the application date):
8. Total number of health
workers in the hospital (according to the hospital’s statistics data before the
application date):
9. Total number of doctors
in the hospital (including full-time, bridging-program and post-graduate
doctors):
10. Total number of nurses
and midwives in the hospital (including post-secondary school, college and
university):
11. Average number of visits
per day (calculated on average 1 month before application):
12. Average number of
inpatients per day (calculated on average 1 month before application):
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14. Position:
15. Cell phone number:
16. Hospital’s email address
(shared or personal email):
* Type of hospital, fill in
numbers from 1 to 9 according to the following contents:
1. Public hospitals
exercising autonomy in recurrent expenditures and investment expenditures;
2. Public hospitals
exercising autonomy in recurrent expenditures;
3. Public hospitals
exercising partial autonomy in recurrent expenditures;
4. Public hospitals with
recurrent expenditures covered by the State;
5. Private hospitals with
domestic owners;
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7. Domestic and foreign
private, joint venture, association hospitals;
8. Other type, specify;
9. Public hospitals
exercising full financial autonomy.