Support Services Quality Control Survey v2.0

Greetings Care Extender! You should be filling out this form if you are volunteering in the following departments in the Santa Monica Hospital: 1) CCU 2) MED SURG 3) ONCO 4) ORTHO 5) PEDS *If you are currently volunteering in the ER, please submit your survey at* After you conduct your survey with the patient, you were asked to keep the hard copy of the survey. Now that the Care Extender program is transitioning more and more forms to the electronic submission, you will also be submitting the results of the survey you took electronically by entering the answers on the hard copy of the survey onto this digital form. If the patient responds to any of the survey questions with anything less than "yes," then it should be recorded as "no." As Care Extenders and members of the hospital staff, we aim to maximize patient satisfaction and cannot expect anything less. Any "sometimes" answers should then be considered as a "no" so that the hospital staff can address the issue to turn it into a "yes" response in the future. As a reminder, you should fill out one of these surveys during EACH ONE of your shifts. Nicely ask the charge nurse or other hospital staff members which patients are available for interview. Practice C-ICARE as you approach patients and explain that you would like to conduct an interview to assess their experiences in the hospital. Do not insist on conducting the survey if the patient has done a survey in the past day or if they are not comfortable conducting a survey. If you have any questions or concerns, please contact me by sending an email to Thanks, Jessica Kim Care Extender Program Administrative Coordinator
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