Physician Practices Survey Template

Physician practices survey, providing an evaluation of hospital and services provided.



   
 
What is your medical specialty?
 
Anesthesiology
 
Cardiovascular surgery
 
Emergency medicine
 
Family practice
 
General surgery
 
Hematology/ Oncology
 
Internal medicine
 
Neonatology
 
Neurology/ Neurosurgery
 
Obstetrics/ Gynecology
 
Otorhinolaryngology
 
Opthalmology
 
Orthopedic/ Surgery
 
Pathology
 
Pediatrics
 
Plastic surgery
 
Psychiatry
 
Radiology
 
Thoracic surgery
 
Urology
 
Other
    
 
   
 
How many years have you been practicing medicine (post-internship)?
 
< 5
 
5-9
 
10-14
 
15-19
 
20 or more
 
   
 
Is your practice
 
Hospital based
 
Individual practice
 
Small group practice (5 or fewer physicians)
 
Large group practice (6 or more physicians)
 
Other
    
 
   
The next section refers to the hospital where you admit the most patients.
Strongly agree Somewhat agree Neutral Somewhat disagree Strongly disagree No opinion
Administration listens to physician concerns
Administration listens to physician concerns, but responds to the wrong physician groups
I have a good professional relationship with administration
During the last year my professional relationship with administration has improved
 
   
Professional referrals may be made based on a number of factors. For each of the following items, please indicate the extent to which you think each is important in selecting a hospital for your patients.
Very Important Important Not too Important Not at all Important No Opinion
The price of hospital services
Your satisfaction with the medical staff
The reputation of the hospital
The reputation of hospital based physicians
The reputation of specialists practicing at the hospital
Communication between you and the consulting physician
Competence of nursing staff
Past experiences of patients
Economic condition of the patient
Convenience of hospital for patient and family
Patient hospital preference
Religious preference
Patient referral
 
   
 
When a patient needs hospital care, who selects the hospital or other care facility?
 
I usually decide
 
I decide based on information from the patient
 
The patient and I decide together
 
The patient decides based on information I provide
 
The patient decides
 
   
 
Thank you for taking the time to respond.
 

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