Take Our Patient Satisfaction Survey
 
 
 
 

We invite you to respond to the following survey questions about your most recent experience with breast cancer treatment, regardless of where you received your care. This survey was developed in collaboration with several national and regional breast cancer organizations who share our commitment to providing women like you with the best care possible. We will use the results of this information to identify the best clinical practices and patient preferences to improve quality of care and clinical performance.

We hope that by posting the results of this survey other breast cancer health care providers will also utilize these results to do the same. (Information posted will be aggregately displayed and no hospital, patient, or doctor identifiers will be listed for confidentiality reasons.) Our ultimate goal is to promote the development and implementation of national quality standards for the diagnosis and treatment of women with breast cancer.

We would like you to rate your responses on the following scale:

    Poor = 1
    Fair = 2
    Good = 3
    Very Good = 4
    Excellent = 5
  Treatment started date: (mm/dd/yyyy)

VISIT-RELATED

1. Registration
a. How promptly were you registered for your visits?
b. The courteousness and helpfulness of the registration staff?
 
2. Blood drawing
a. How promptly your blood was drawn?
b. How skillfully and painlessly your blood was drawn?
 
3. Radiology
a. How conveniently your x-rays were scheduled?
b. How promptly your x-rays were performed?
c. The courteousness of the x-rays staff?
d. The skill of the x-ray staff?
 
4. Nursing
In some instances when you received breast cancer care you may have received the care from a nurse in the outpatient setting rather than from a physician. If this is true for you please answer the following questions; if not then skip to section #5.
a. How promptly you were seen for scheduled visits with the nurses?
b. The knowledge and skill of the nurses?
c. The courteousness of the nurses?
d. The sensitivity of the nurses?
 
5. Doctors
a. How promptly you were scheduled for visits with your breast cancer doctors?
b. The knowledge and skill of the breast cancer doctors?
c. The courteousness of the breast cancer doctors?
d. The sensitivity of the breast cancer doctors?
 
6. Check-Out Process from the Outpatient Setting
a. How promptly you were able to check-out after a visit for your breast cancer in the outpatient setting?
b. The scheduling of future appointments at a time that was convenient for you?
c. The courteousness and helpfulness of the check-out staff?
CARE RELATED
 
1. Diagnosis
a.Where was your breast cancer diagnosed?
  
Name:
City:
State:
Who was the doctor who made the diagnosis?
b. How quickly and without delay your breast cancer diagnosis was made?
c. How fully and clearly you were informed about your diagnosis?
d. The accuracy of your diagnosis as far as you know?
 
2. Surgery
a.Where was your breast cancer surgery performed?
Name:
City:
State:
Who was the doctor who performed your breast cancer surgery?
If you had reconstruction, who was the doctor who performed this part of the surgery?
b.What breast cancer surgery did you have?
Left Mastectomy
Left Mastectomy with Implant
Left Mastectomy with flap reconstruction
Right Mastectomy
Right Mastectomy with Implant
Right Mastectomy with flap reconstruction 		Bilateral Mastectomy
Bilateral Mastectomy with Implant
Bilateral Mastectomy with flap reconstruction

Left Lumpectomy
Right Lumpectomy
c. How complete the information was about the different types of breast cancer surgery?
d. How complete the information was about the possible benefits or harm from the different types of breast cancer surgery?
e. Your participation in the decision about which breast cancer surgery was better for you?
f. Your participation in the decision to have your surgery as an outpatient (if you did)?
g. Were you comfortable with the guidance your doctor gave you about the type of surgery you could have?
h. How promptly your surgery was performed?
i. The preparation before the operation for how you would feel afterward?
j. The handling of concerns you had after surgery?
k. The competence and skill of the doctors and staff who took care of you?
l. The surgical care you received overall?
 
3. Home Health Care
Did you receive home health care after your surgery?
Yes    No (if no, skip to section #4)
a. How skilled were the home health nurses?
b. How sensitive to your needs were the home health nurses?
 
4. Radiation Therapy
Did you receive therapy?
Yes    No (if no, skip to section #5)
If yes, where was the radiation therapy performed?
Hospital
Outpatient Radiation Facility
Other
Name:
City:
State:
Who was your radiation oncologist?
a. How fully informed you were about the potential benefits and harm of radiation therapy?
b. Your participation in the decision to receive radiation therapy?
c. How long you had to wait for your individual radiation treatments?
d. The skill of the radiation therapy technicians?
e. The courtesy of the radiation therapy technicians and doctors?
f. How well prepared you were before your radiation therapy for how it made you feel?
g. How promptly any concerns you had with radiation therapy were handled?
h. How carefully any concerns you had with radiation therapy were handled?
i. The radiation therapy you received overall?
 
5. Adjuvant Chemotherapy
Did you receive adjuvant chemotherapy?
Yes    No (if no, skip to section #6)
If yes, where was the adjuvant chemotherapy performed?
Inpatient Hospital Setting
Outpatient Hospital Setting
Outpatient Clinic
Home Health Care
Name:
City:
State:
Who was your doctor for your chemotherapy treatment and follow up care?
a. How fully informed you were about the potential benefits and harm of adjuvant chemotherapy?
b. Your participation in the decision-making about whether you should receive adjuvant chemotherapy?
c. How long you had to wait for your adjuvant chemotherapy treatments?
d. The skill of the nurses and doctors who administered your adjuvant chemotherapy?
e. The courteousness of the nurses who administered your adjuvant therapy?
f. How well prepared you were before chemotherapy for how it made you feel?
g. How promptly any concerns you had with adjuvant chemotherapy were handled?
h. How carefully any concerns you had with adjuvant chemotherapy were handled?
i. The adjuvant chemotherapy you received overall?
 
6. Hormonal Therapy
Did you receive hormonal therapy?
Yes    No (if no, skip to section #7)
a. How fully informed you were about the potential benefits and harm of hormonal therapy?
b. Your participation in the decision about whether you should receive hormonal therapy?
c. How well-prepared you were for how hormonal therapy made you feel?
 
7. Coordination of Care
a. The coordination of the breast cancer care you received from the doctors and nurses involved in your treatment?
8. Psychosocial Aspects of Care
a. How well informed you were about the psychological and social problems caused by breast cancer and its treatment?
b. How well informed you were about services at the site where you received your breast cancer treatment and in the community for dealing with the psychological and social problems caused by breast cancer and its treatment?
c. How effectively the psychological and social aspects of your breast cancer and its treatment were addressed?
d. Have you attended any support group meetings?
Yes No
If yes, how helpful was it?
e. Did you talk with a social worker for assistance or support during your treament?
Yes No
f. Did you talk with a breast cancer survivor provided by the hospital or doctor's office where you were treated?
Yes No
Do you recall the name of the survivor?
 
9. Post-Treatment Medical Care
a. How well prepared you were for any of the concerns you had after your breast cancer treatment was completed?
b. How promptly and how thoroughly any concerns you have had after treatment have been handled?
 
10. Urgent Problems and Emergencies
a. How well prepared you were by your doctors and nurses who treated you for breast cancer about what to do in case of an urgent problem or emergency?
b. How available the doctors and nurses were to you at the site where you received your breast cancer treatment when you developed an urgent problem or emergency? (Anser N/A if not applicable)
c. How available the doctors and nurses have been to you for walk-in visits at the site where you received your breast cancer treatment when you developed an urgent problem or emergency? (Answer N/A if not applicable)
 
11. Education
a. How educated you were about your breast cancer and its treatment (this includes all sources of education available at the site where you received your breast cancer treatment; i.e., staff, books, pamphlets, audiovisual materials)?
b. How effectively the doctors and nurses at the site where you received your breast cancer treatment educated you about your breast cancer and its treatment?
 
12. Overall Evaluation
a. How satisfied were you about the care you received for your breast cancer treatment overall?
 
13. We are interested if you would recommend the site where you received your breast cancer to family members or friends. Would you say:
Definitely would not Probably would
Probably would not Definitely would
 
14. What comments or suggestions do you have for how to improve the care for women diagnosed and treated for breast cancer? Please try to comment on those areas you rated poor or fair in this survey.
 
15. Your breast cancer was diagnosed:
0-2 years ago
3-5 years ago
6-10 years ago
11-15 years ago
16-20 years ago
>20 years ago
 
16. In choosing where you had your treatment, would you rate the value of the following statements: Please use the scale of 1 to 5, 1 meaning "not important" and 5 meaning "very important."
a. Reputation of the institution
b. Reputation of the doctors
d. Reputation of the nursing staff
d. Ease of communicating with physicians and nurses
e. Confidence in decisions made about care
f. Location of facility
g. Prior familiy experience at the institution
h. Prior experience of a friend at the institution
i. My insurance company chose for me
 
17. Which insurance coverage did you have at the time of your breast cancer treatment?
Medicare Medicaid Blue Cross
Commercial Insurance Which one? 
HMO/Managed Care Org. Which one? 
 
18.
Your age at the time you were diagnosed with breast cancer:
Your age today:
 
19.
What city do you live in?
What state do you live in?
What is your zip code?
 
20.
Optional - Your E-mail address: 

Thank you for taking your valuable time to participate in this survey. Click here to submit your answers:
 
 
 
 
 

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