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Specialist Consultation Template -Form Fill

IDENTIFICATION PARTICULARS
Q01

Name of the respondent
Q02

Name and Code of the District
Q03

Is the Institution Urban or Rural?
Q04

Name of City/Town/Village in which the institution is situated
Q05

Name and Code of the Digital Dispensary
Q06

Name and code of interviewer
Q07

Name and code of Supervisor
CONSENT INFORMATION
A01

Date of taking consent
A02

Consent was Given and interviewed.
A03

Start time of interview and end time to be auto coded
RESPONDENT CHARACTERISTICS
B01

Name of the respondent
B02

Gender of the respondent?
B03

How old were you on your last birthday?
B04

What is your religion?
B05

What is your Caste
B06

What is your marital status?
B07

What is the highest level of education you have completed?

B08

What is your current occupation status?
B09

What type of primary employment are you engaged in?
B10

How much do you earn in a month? (Amount in Rs.)
B11

Do you live with your family?
B12

Are you the chief earning member of your household?
B13

How many members are there in your family?
B14

Does any of your family members suffer from chronic illnesses (diabetes, hypertension, cancer, kidney disease, Asthma, COPD)
B15

How many of them are suffering from chronic illnesses
B16

Does your household have a BPL card?
B17

What is your monthly family income from all the sources?
ACCESSIBILITY TO THE INSTITUTION
C01

Specify the type of service you have availed at the DD
C02

Which Specialist Care have you availed at the DD?
C03

Were you referred to this DD for specialist care by another doctor?
C04

Please Specify from which facility you are referred to this DD for specialist care?
C05

In the Absence of Specialist care at GLOCAL DD, where would you have gone for the specialist care?
C06

How far would have been the nearest specialist care, in the absence f this DD?
C07

How did you first come to know about this facility?
C08

Since when did you seek care from this institution?
C09

From where did you seek healthcare earlier?
C10

When was the last time you visited this facility?
C11

Since you visited this institution for the first time, have you ever had to approach any other Care provider/institution for your healthcare needs?
C12

What was/were the reason(s) for you to skip this institution?
C13

What is the approximate distance between your residence and this facility?
C14

What is the approximate time taken for your travel to the facility?
C15

How did you reach the facility?
C16

How much did you spend on travelling to the facility?
C17

What is the condition of the road from your residence to the facility?
C18

Do you think this facility is located at a place easily accessible by most of the surrounding population?
C19

Does the Institution provide any virtual follow-up assistance 24x7? (Eg: through telephone/any other online mode)
C20

What is the existing model for virtual follow up 24x7?
C21

Do think having virtual consultations with the institutions 24x7 would be useful?
C22

How would you rate the overall accessibility to this institution?
AFFORDABILITY OF THE INSTITUTIONAL SERVICES
D01

Did you have to pay for any medications/ diagnostic facilities/ any other out of pocket expenses?

D02

For which all services did you pay?

D03

How much did you spend on each service at this facility?

D03_1

Consultation
D03_2

Medicine/Consumables
D03_3

Lab/Diagnostic Tests
D03_4

In-patient Services
D03_5

Service procedures
D04

How much do you spend on Out-Patientcare in other hospitals/clinics on average?
D05

How much did you spend on In Patient care for a similar illness at another hospital on average?
D06

Do you think this facility is more affordable than a govt PHC/Hospital?
D07

Do you think this facility is more affordable than a private hospital of similar capacity?
D08

Have you been worried about the cost of seeking care at this institution?
D09

Have you faced any financial challenges in seeking care at this institution?
D10

Which component of healthcare caused you the financial challenge?
D11

What is the source of finance that paid for your care at this institution?
D12

Have you felt any specific component particularly costly at the institute?
D13

Which part of health care did you feel unreasonably costly?
D14

On average, how would you rate the affordability at this institution?
D15

Do you recommend it to your friends & relatives this facility with respect to its affordability?
QUALITY OF SERVICES AT THE DD
E01

Are you visiting this institute for the first time?
E02

How many times have you visited the facility in the last six months, either as a patient or bystander? (record the number of visits. Eg: 2 times the in last six months, 0 times in last six months)
E03

Have you noticed any visible improvements in the functioning of the institution?
E04

Were your complaints addressed properly each time you visited the facility?
E05

Have you faced any difficulty in finding the registration counter after your arrival?
E06

Do you have to make a registration every time you visit the facility?
E07

Is there a possibility of making an outpatient booking in advance?
E08

Have you felt the need for outpatient booking in advance?
E09

On average, what is the waiting time for consultation after arriving at the institution’s premises?
E10

Have you faced a long waiting time at any point during your visit?
E11

Where did you face the delay in securing the service?
E12

How long did you wait at that point?
E13

Have you ever faced any problems due to the non-availability of doctor’s service on time during your visit to the facility?
E14

What was the duration of your consultation?
E15

During your entire visit, were you given proper instructions in a way you could understand?
E16

At what point have you felt the instructions were not clear?
E17

How often were the DD staff cordial and respectful to you during your entire visit?
E18

How would you rate the promptness of the staff in attending to your health need?
E19

Do you think the dispensary staff are competent to attend to your complaints?
E20

Which category of healthcare provider do you think is incompetent
E21

Have you ever faced the unavailability of prescribed medicine at the in-house pharmacy?
E22

Have you ever had to depend on an outside laboratory for a prescribed diagnostic test from this dispensary?
E23

Have you ever had to depend on an outside laboratory for a prescribed radiological/imaging technique from this dispensary?
E24

Is the DD/ACH-OP equipped with proper signage and direction boards in a way understandable to you?
E25

Does the DD have proper waiting areas with enough seating arrangements?
E26

Does the DD is equipped with a drinking water facility?
E27

Did the DD have wheelchair amenities?
E28

Is the toilet facility at the institute adequately maintained?
E29

How would you rate the overall cleanliness of the institution?
E30

Do you think you are reasonably aware of all the services available at the dispensary?
E31

What was the chief reason for you to choose this institution?
E32

Do you think the DD is an improvement on the earlier PHC or other PHCs that you have encountered?
E33

Using any number from 0 to 10, where 0 is the worst Dispensary possible and ten is the best possible, what number would you use to rate this dispensary during your visit?

E34

Would you recommend this DD to your friends and family based on the quality of service here?

TELE-CONSULTATION USABILITY AND SATISFACTION SURVEY AT DD
F01

Now I will give you a few statements on teleconsultation, to which you may agree or disagree depending on your experience. Kindly give a score from 1 to 5 to mark your agreeability to each statement, with 1 Strongly disagreeing and 5 Strongly agreeing

F01_1

Telehealth consultation improves my access to healthcare services.
F01_2

Telehealth saves me time travelling to a specialist referral hospital
F01_3

This facility saved my time & other opportunity costs.
F01_4

This facility saved the cost of illness care substantially
F01_5

The teleconsultation interface was simple to interact
F01_6

The way I interact with this system is pleasant.
F01_7

I can easily talk to the clinician using the telehealth system.
F01_8

I can hear the clinician clearly using the telehealth system.
F01_9

I felt I was able to express myself effectively
F01_10

Using the telehealth system, I can see the clinician as well as if we met in person.
F01_11

I think the visits provided over the telehealth system are the same as in-person visits.
F01_12

Prompt technical assistance was provided at the institution whenever there was an issue with the system
F01_13

My history was taken, and vitals were recorded prior to my consultation.
F01_14

I was treated with courtesy, respect, sensitivity and friendliness by the telehealth staff
F01_15

My privacy was respected by the DD staff during the consultation
F01_16

I felt comfortable communicating with the clinician using the telehealth system.
F01_17

Telehealth is an acceptable way to receive healthcare services.
F01_18

I would use telehealth services again.