Surgery Quality Improvement Form
Provide your feedback to help us improve surgery workflow and outcomes. Please do not include any sensitive or personal health information.
Your role in the surgical process
*
Please Select
Surgeon
Nurse
Anesthesiologist
Surgical Tech
Administrator
Other
Date of surgery (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgical department
*
Please Select
General Surgery
Orthopedics
Cardiac
Neurosurgery
ENT
Other
How would you rate the overall workflow efficiency?
*
1
2
3
4
5
Were there any workflow delays or bottlenecks?
*
No
Minor delays
Significant delays
How would you rate communication among team members?
*
1
2
3
4
5
Were all necessary resources and equipment available?
*
Yes, everything was available
Some items missing but did not impact outcome
Critical items missing, impacted workflow
How would you rate the outcome of the surgery?
*
1
2
3
4
5
What went well during the surgery workflow?
Suggestions for improvement
Would you recommend any changes to the current workflow?
*
No changes needed
Minor adjustments
Major changes needed
Submit Feedback
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