Quality in Family Practice
Patient Questionnaire – Instructions for Practices
Patient satisfaction is considered an indicator of quality of care. A patient satisfaction questionnaire
can be used to assess the performance of health care delivery at the family practice level.
Use of the Patient Questionnaire
The Quality in Family Practice Patient Questionnaire was developed with careful consideration of
what is being measured. Patient satisfaction can address many aspects of care. The patient
questionnaire will be important for assessing specific criteria in the Quality in Family Practice
Assessment Tool, including those related to the needs and rights of patients, access and availability,
barriers to access, patient-centredness, practice’s physical facilities, clinical practice systems, patient
information management, and continuity of care. The questions in the questionnaire are meant to
help practices evaluate specific criteria and improve their care. Therefore, questionnaire items are
not vague or general. Rather, they relate to specific aspects of care (i.e. Quality in Family Practice
criteria), where there is clearly something to be done, if the practice judges that improvement is
needed. There are NO right or wrong answers. Rather, it is the task of the family practice to interpret
patient responses. It will be useful for the practice team to assimilate and reflect on the survey results
in order to complete their self-assessment.
Questionnaire Development
The Quality in Family Practice Patient Questionnaire is a patient-friendly form that is easy to
understand with a maximum length of two pages. The questionnaire should take no longer than 15
minutes for patients to complete. The Physician Achievement Review (PAR) Patient Questionnaire
provided the model for the first draft of the Quality in Family Practice Patient Questionnaire (and
other Quality in Family Practice questionnaires). The rating scale used by PAR was retained, but the
table format was altered. Individual PAR items that were relevant for the Quality in Family Practice
criteria were included (some with slight revision) in our questionnaire. Several Quality in Family
Practice criteria were not addressed by the PAR items. For these criteria, some items were taken
from other existing patient surveys. Other items were constructed by the Quality in Family Practice
research team.
Patient Questionnaire
This is a survey to find out your thoughts about this practice and the health care provided.
Feedback from this survey will be used to improve services. The survey has a number of
statements about the practice and its staff. Please circle your response for each statement. This
form is used by a variety of patients; therefore, not all of the following items may be relevant to
you. If any of these items are NOT applicable to you, circle “NA”. There are no right or wrong
answers – we are simply interested in your views.
Gender: □ Male □ Female
Age: □ 25 or under □ 26-34 □ 35-44
□ 45-54 □ 55-64 □ 65 or over
Over the last five years, how often have you seen this doctor?
□ Once □ 2-3 times □ Over 3 times
Today’s visit is mainly for:
□ New concern □ Ongoing concern □ Examination
Provider’s name:
This is an anonymous survey – you should not put your name on it.
Thank you for taking time to complete this questionnaire.
Quality Patient Questionnaire Draft 1 May 2005
Patient Questionnaire
Strongly Disagree Neutral Agree Strongly
Disagree Agree
1 2 3 4 5 NA
Based on your visits to this office, how do you feel about
your health care provider’s attitude and behavior
towards you? My provider:
1. Spends enough time with me 1 2 3 4 5 NA
2. Shows interest in my problems 1 2 3 4 5 NA
3. Asks details about my personal life, when appropriate 1 2 3 4 5 NA
4. Answers my questions well 1 2 3 4 5 NA
5. Examines me appropriately for my problems 1 2 3 4 5 NA
6. Treats me with respect 1 2 3 4 5 NA
7. Helps me with my fears and worries 1 2 3 4 5 NA
8. Explains my illness or injury to me thoroughly 1 2 3 4 5 NA
9. Adequately explains my treatment choices 1 2 3 4 5 NA
10. Explains my problem and how to avoid it in the future 1 2 3 4 5 NA
11. Explains when to return for follow-up care 1 2 3 4 5 NA
12. Clearly explains how and when to take my medicine 1 2 3 4 5 NA
13. Tells me of any side effects of the medicine 1 2 3 4 5 NA
14. Tells me how I will find out the results of my medical 1 2 3 4 5 NA
test(s)
Rate each statement about this doctor’s office.
15. The practice is easy to get into (e.g. wheelchair 1 2 3 4 5 NA
accessible, parking)
16. The practice is easy to get around in – there are good 1 2 3 4 5 NA
signs and easy access
17. The practice has appropriate waiting areas 1 2 3 4 5 NA
18. Examining rooms are adequately sized and have 1 2 3 4 5 NA
adequate equipment
19. The practice is clean and in good repair 1 2 3 4 5 NA
20. There is adequate privacy 1 2 3 4 5 NA
21. I can contact the practice on the telephone easily 1 2 3 4 5 NA
Quality Patient Questionnaire Draft 1 May 2005
Strongly Disagree Neutral Agree Strongly
Disagree Agree
1 2 3 4 5 NA
22. I receive an appropriate explanation if my appointment 1 2 3 4 5 NA
is delayed
23. My messages are returned 1 2 3 4 5 NA
24. The staff are polite and friendly 1 2 3 4 5 NA
25. The staff are very capable 1 2 3 4 5 NA
26. The staff are respectful of patients 1 2 3 4 5 NA
27. The staff behave in a professional manner 1 2 3 4 5 NA
28. The staff work well together 1 2 3 4 5 NA
29. I can usually get an appointment within a reasonable 1 2 3 4 5 NA
time
30. If I need to, I can see a doctor on short notice 1 2 3 4 5 NA
31. I do NOT wait long in the reception area for my 1 2 3 4 5 NA
appointment
32. My provider arranges appointments with other 1 2 3 4 5 NA
specialists when necessary
33. The practice follows up on any serious problems I may 1 2 3 4 5 NA
have
34. I am told what to do if my problems do not get better 1 2 3 4 5 NA
35. I am able to reach the after hours service by telephone 1 2 3 4 5 NA
36. In an emergency situation, the practice provides me with 1 2 3 4 5 NA
clear instructions on what I am to do
37. I am able to see my usual provider (or provider of my 1 2 3 4 5 NA
choice)
38. I am given the opportunity to make compliments or 1 2 3 4 5 NA
complaints to this office about its service and quality of
care
39. I can get my prescription(s) refilled without a visit 1 2 3 4 5 NA
40. When asked, I am provided with reports, files or copies 1 2 3 4 5 NA
of letters
General:
41. My provider talks to me about preventative care (e.g. 1 2 3 4 5 NA
quitting smoking, weight control, sleeping, alcohol,
exercise, etc.)
42. My provider has good written health information 1 2 3 4 5 NA
43. My provider refers me to appropriate education 1 2 3 4 5 NA
resources (i.e. websites, brochures, patient support
groups, books)
44. My provider asks regularly about prescription medicine I 1 2 3 4 5 NA
may be taking
Quality Patient Questionnaire Draft 1 May 2005