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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: chatluongbenhvien@gmail.com.The 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.