Va 4

B

OMB Number 2900-new
Est. Burden: 30 minutes
VA Form 10-21083e(NR)

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
RECENTLY DISCHARGED INPATIENT 2006

In order for the VA to carry out its mission to provide the best possible medical care and services to all
veterans, it is extremely important that you complete and return this questionnaire. Your answers help
ensure that all veterans receive the highest quality care they have earned and so richly deserve.
We want to remind you that all information is strictly anonymous. It will not be shared with your doctor
or affect your VA care.
Please read each question and fill in the circle that best describes your experience. Use blue or black ink
pen, or pencil. Please be sure to read all pages of this booklet.

The Paperwork Reduction Act of 1995
This information is collected in accordance with section 3507 of the Paperwork Reduction Act
of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the
time expended by all individuals who complete this survey will average 30 minutes. This
includes the time it will take to read instructions, gather the necessary facts and fill out the
form. Surveys of healthcare experiences are used to gauge customer perceptions of VA
services as well as gather information on patient's functional status and health behaviors.
The results of this survey will lead to improvements in the quality of service delivery by helping
to shape the direction and focus of specific programs and services. Disclosure of information
involves release of statistical data and other non-identifying data for the improvement of
services within the VA healthcare system and associated administrative purposes.
Submission of this form is voluntary and failure to respond will have no impact on benefits
to which you may be entitled.

Please answer all survey questions about your hospitalization at:

B

Alpha Hospital, ending on March 3, 2005.

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***ABOUT YOUR MOST RECENT VA HOSPITALIZATION 2006***
Please read each question and fill in the circle that best describes your experience.
Use blue or black ink pen.

***ADMISSION***

1. Was your hospital stay an emergency or planned in advance?
E Emergency
E Planned in advance
2. How organized was the admission process?
E Not at all organized
E Somewhat organized

E Very organized

3. During your admission did you get enough information about your medical condition and treatment?
E Yes, definitely
E Yes, somewhat
E No
E Did not want information
4. Do you feel you had to wait too long before you got to your room?
E Yes, definitely
E Yes, somewhat
E No
5. If you had to wait to go to your room, did someone from the hospital explain the reason for the delay?
E Yes
E No
E Did not have to wait
6. How would you rate the courtesy of the staff who admitted you?
E Poor
E Fair
E Good
E Very Good
E Excellent
***DOCTORS***

7. Was there one particular doctor in charge of your care in the hospital?
E Yes
E No
E Not sure
8. When you had important questions to ask a doctor, did you get answers you could understand?
E Yes, always
E Yes, sometimes
E No
E Did not have questions
9. If you had any anxieties or fears about your condition or treatment, did a doctor discuss them with you?
E Yes, completely
E Yes, somewhat
E No
E Did not have anxieties or fears
10. Did you have confidence and trust in the doctors treating you?
E Yes, always
E Yes, sometimes
E No

B

11. Did doctors talk in front of you as if you weren't there?
E Yes, often
E Yes, sometimes
E No
12. How would you rate the courtesy of your doctors?
E Poor
E Fair
E Good
E Very Good

E Excellent

13. How would you rate the availability of your doctors?
E Poor
E Fair
E Good
E Very Good

E Excellent

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***NURSES***

14. When you had important questions to ask a nurse, did you get answers you could understand?
E Yes, always
E Yes, sometimes
E No
E Did not have questions
15. If you had any anxieties or fears about your condition or treatment, did a nurse discuss them with you?
E Yes, completely
E Yes, somewhat
E No
E Did not have anxieties or fears
16. Did you have confidence and trust in the nurses treating you?
E Yes, always
E Yes, sometimes
E No
17. Did nurses talk in front of you as if you weren't there?
E Yes, often
E Yes, sometimes
E No
18. How would you rate the courtesy of your nurses?
E Poor
E Fair
E Good
E Very Good

E Excellent

19. How would you rate the availability of your nurses?
E Poor
E Fair
E Good
E Very Good

E Excellent

***HOSPITAL STAFF***

20. Did you have trouble understanding the provider because of a language problem?
E Yes, definitely
E Yes, somewhat
E No
21. Sometimes in the hospital, one doctor or nurse will say one thing and another will say something quite different.
Did this happen to you?
E Yes, always
E Yes, sometimes
E No
22. Did a doctor or nurse explain the results of tests in a way you could understand?
E Yes, completely
E Yes, somewhat
E No
E No tests were done
23. Was personal information about you treated in a confidential manner?
E Yes, always
E Yes, sometimes
E No
24. Did you have enough say about your treatment?
E Yes, definitely
E Yes, somewhat
E No
25. Did your family or someone else close to you have enough chances to talk to your doctor?
E Yes, definitely
E No
E Family did not want or need information
E Yes, somewhat
E No family or friends involved
26. How much information about your condition or treatment was given to your family or someone close to you?
E Not enough
E Too much
E Family did not want or need information
E Right amount
E No family or friends involved

B

27. Was it easy for you to find someone on the hospital staff to talk to about your concerns?
E Yes, definitely
E Yes, somewhat
E No
E Did not want to talk/no concerns

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28. Did you have enough privacy?
E Yes
E No
29. When you needed help eating, bathing, or getting to the bathroom, did you get it in time?
E Yes, always
E Yes, sometimes
E No
E Did not need help
30. How many minutes after you used the call button did it usually take before you got the help you needed?
E 0 to 5 minutes
E 11 to 15 minutes
E More than 30 minutes
E Never used call button
E 6 to 10 minutes
E 16 to 30 minutes
E Never got help
E No call button available
31. When you had pain, was it usually severe, moderate, or mild?
E Severe
E Moderate
E Mild
E Did not have pain
32. How many minutes after you asked for pain medicine did it usually take before you got it?
E 0 to 5 minutes
E 16 to 30 minutes
E Never asked for pain medicine
E 6 to 10 minutes
E More than 30 minutes
E Didn't have pain
E 11 to 15 minutes
E Never got pain medicine
33. Do you think that the hospital staff did everything they could to help control your pain?
E Yes, definitely
E Yes, somewhat
E No
E Didn't have pain
34. Overall, how much pain medicine did you get?
E Not enough
E Right amount
E Too much

E Didn't have pain

35. Sometimes people who are in pain don't ask for pain medication. Was this true for you?
E Yes
E No
E Did not have pain
36. If you answered yes to the question above, was it because...
E You were concerned it might be habit forming
E A patient should expect to put up with some pain
E You felt it would be a bother if you asked for it
E No one told you pain medication was available
E You were concerned about possible side effects
E You were concerned about what might happen if you mixed pain medications with your other medication
E Other
37. Did you feel like you were treated with respect and dignity while you were in the hospital?
E Yes, always
E Yes, sometimes
E No
38. Did you feel that you were treated like a second class citizen?
E Yes
E No

B

39. Your Room
a. cleanliness of your room
E Poor
E Fair
E Good

E Very Good

E Excellent

E Does Not Apply

b. privacy in your room
E Poor
E Fair

E Good

E Very Good

E Excellent

E Does Not Apply

c. noise level
E Poor

E Good

E Very Good

E Excellent

E Does Not Apply

d. sense of safety and security
E Poor
E Fair
E Good

E Very Good

E Excellent

E Does Not Apply

E Fair

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40. Equipment and Facilities
a. ease of finding your way around the hospital
E Poor
E Fair
E Good
E Very Good

E Excellent

E Does Not Apply

b. availability of parking
E Poor
E Fair

E Good

E Very Good

E Excellent

E Does Not Apply

c. cost of parking
E Poor
E Fair

E Good

E Very Good

E Excellent

E Does Not Apply

***GOING HOME***

41. Did someone on the hospital staff explain the purpose of the medicines you were to take at home in a way you
could understand?
E Yes, completely
E No
E No medicines at home
E Yes, somewhat
E Did not need explanation
42. Did someone on the hospital staff tell you about medication side effects to watch for when you went home?
E Yes, completely
E No
E No medicines at home
E Yes, somewhat
E Did not need explanation
43. Did someone on the hospital staff tell you about what problems about your illness or operation to watch for after
you went home?
E Yes, completely
E Yes, somewhat
E No
44. Did someone on the hospital staff tell you what activities you could do after you got home (such as driving, walking
up steps, lifting, sex)?
E Yes, completely
E Yes, somewhat
E No
45. Did the hospital staff give your family or someone close to you all the information they needed to help you recover
after you got home?
E Yes, definitely
E No
E Family did not want or need information
E Yes, somewhat
E No family or friends involved
46. Did you know who to contact if you needed medical advice or help right away, after you went home?
E Yes, always
E Yes, sometimes
E No

***OVERALL IMPRESSIONS***

47. How would you rate how well the doctors and nurses worked together?
E Poor
E Fair
E Good
E Very Good
E Excellent
E Do not know
48. Overall, how would you rate the quality of care you received at the hospital?
E Poor
E Fair
E Good
E Very Good
E Excellent

B

49. If you could have free care outside the VA, would you choose to be hospitalized here again?
E Definitely would not
E Probably would not
E Probably would
E Definitely would

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50. How would you rate your health now?
E Poor
E Fair
E Good
E Very Good

E Excellent

51. Did you have a complaint about how you were treated (medically or personally) during your last hospitalization?
E Yes
E No
52. If you reported this complaint to someone at the VA location where you received your care, to whom did you report
this complaint?
E Treatment Team
E Patient Advocate
E Other VA Staff
E Did not report the complaint to a VA employee
53. If you had a complaint, how easy was it for you to find someone to hear your complaint? (Fill in only one circle)
Very easy
Easy
Difficult
Very difficult
Not Applicable
E
E
E
E
E

54. If you spoke with someone at the VA location about a complaint, how satisfied were you with the way your
complaint was handled?
E Very satisfied
E Satisfied
E Dissatisfied
E Very dissatisfied

55. How long did it take for the VA hospital to resolve your complaint?
E Same day
E 8-14 days
E More than 21 days
E 2-7 days
E 15-21 days
E Complaint is not resolved

E I did not have a complaint

***ABOUT YOUR HEALTH***

Instructions: The following questions ask for your views about your health.

B

Please answer every question by filling in one circle for each answer. If you are unsure about how to answer a
question, please give the best answer you can.

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56. In general, would you say your health is...
E Excellent
E Very Good
E Good

E Fair

E Poor

57. The following two questions are about activities you might do during a typical day. Does
your health now limit you in these activities? If so, how much?
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
E Yes, Limited A Lot
E Yes, Limited A Little
E No, Not Limited At All
b. Climbing several flights of stairs?
E Yes, Limited A Lot
E Yes, Limited A Little

E No, Not Limited At All

58. During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health?
a. Accomplished less than you would like
E No, none of the time
E Yes, some of the time
E Yes, a little of the time
E Yes, most of the time

E Yes, all of the time

b. Were limited in the kind of work or other activities
E No, none of the time
E Yes, some of the time
E Yes, a little of the time
E Yes, most of the time

E Yes, all of the time

59. During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)?
a. Accomplished less than you would like
E No, none of the time
E Yes, some of the time
E Yes, a little of the time
E Yes, most of the time

E Yes, all of the time

b. Didn't do work or other activities as carefully as usual
E No, none of the time
E Yes, some of the time
E Yes, a little of the time
E Yes, most of the time

E Yes, all of the time

60. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home
and housework)?
E Not at all
E A little bit
E Moderately
E Quite a bit
E Extremely

These three questions are about how you feel and how things have been with you during the past 4 weeks. For
each question, please give the one answer that comes closest to the way you have been feeling.

B

61. How much of the time during the past 4 weeks:
a. Have you felt calm and peaceful?
E All of the time
E A good bit of the time
E Most of the time
E Some of the time

E A little of the time
E None of the time

b. Did you have a lot of energy?
E All of the time
E A good bit of the time
E Most of the time
E Some of the time

E A little of the time
E None of the time

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61. How much of the time during the past 4 weeks:
c. Have you felt downhearted and blue?
E All of the time
E A good bit of the time
E Most of the time
E Some of the time

E A little of the time
E None of the time

62. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your
social activities (like visiting with friends, relatives, etc.)?
E All of the time
E A good bit of the time
E A little of the time
E Most of the time
E Some of the time
E None of the time

Now we'd like to ask you some questions about how your health may have changed.
63. Compared to one year ago, how would you rate your physical health in general now?
E Much better
E Somewhat better
E About the same
E Somewhat worse

E Much worse

64. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or
irritable) now?
E Much better
E Somewhat better
E About the same
E Somewhat worse
E Much worse
65. How much of the time during the past week, did you feel depressed?
E Rarely or none of the time (less than 1 day)
E Some or a little of the time (1-2 days)
E Occasionally or a moderate amount of the time (3-4 days)
E Most or all of the time (5-7 days)
66. In the past year, have you had 2 weeks or more when you felt sad, blue or depressed or when you lost interest or
pleasure in things that you usually cared about or enjoyed?
E Yes
E No
67. Have you had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay
sometimes?
E Yes
E No
68. Have you been treated by a VA provider for chronic pain in the past 12 months?
E Yes
E No
69. If you have been treated by a VA provider for chronic pain, please rate the effectiveness of your pain treatment?
E Poor
E Fair
E Good
E Very Good
E Excellent

***OTHER QUESTIONS ABOUT YOU***

Please answer the following questions. We want to remind you that all information is strictly confidential. It will
not be shared with your doctor or affect your VA care.

B

70. Are you of Hispanic or Latino origin or descent?
E Yes, I am Hispanic or Latino
E No, I am not

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71. What is your race? (mark all that apply)
E White (Caucasian)
E Black or African American
E Asian
E Native Hawaiian or Pacific Islander
E American Indian or Alaska Native
72. What is the last year of school you have completed?
E Did not complete high school
E Some college
E High school graduate or GED
E College graduate or beyond
73. What is your current marital status?
E Married
E Divorced
E Separated
74. Are you currently...
E Employed for wages
E Self-employed
E Unable to work

E Widowed

E Never married

E Looking for work and unemployed for more than 1 year
E Looking for work and unemployed for less than 1 year
E Homemaker

E Student
E Retired

75. What was your total household income (income from all sources) during the past 12 months?
E $15,000 or less
E $15,001 to $30,000
E $30,001 to $60,000
E $60,001 or more
76. How tall are you without shoes on? (Fill in feet (ft.) and inches (in.)) (If 1/2" round up)
E 5ft 0in or less
E 5ft 3in
E 5ft 6in
E 5ft 9in
E 6ft 0in
E 6ft 3in or more
E 5ft 1in
E 5ft 4in
E 5ft 7in
E 5ft 10in
E 6ft 1in
E 5ft 2in
E 5ft 5in
E 5ft 8in
E 5ft 11in
E 6ft 2in
77. How much do you weigh? (in pounds) (Fill in one)
E 90 lbs. or less
E 131-140 lbs.
E 181-190 lbs.
E 91-100 lbs.
E 141-150 lbs.
E 191-200 lbs.
E 101-110 lbs.
E 151-160 lbs.
E 201-210 lbs.
E 111-120 lbs.
E 161-170 lbs.
E 211-220 lbs.
E 121-130 lbs.
E 171-180 lbs.
E 221-230 lbs.

E
E
E
E
E

231-240 lbs.
241-250 lbs.
251-260 lbs.
261-270 lbs.
271-280 lbs.

E
E
E
E

78. During the past 12 months, have you been seen by...(fill in one)
E VA providers only
E Non-VA providers only
E VA and non-VA providers

281-290 lbs.
291-300 lbs.
301-310 lbs.
311 lbs. and over

E No providers

79. Do you have one person who you think of as your regular doctor?
E Yes, a VA doctor
E Yes, a non-VA doctor
E No
80. Do you have Medicare coverage? (mark all that apply) Medicare is a federal health program for seniors over 65 and
certain younger disabled people.
E Yes, for hospital care (Part A)
E Yes, for the Medicare+Choice or HMO plan (Part C)
E Yes, for doctor office visits (Part B)
E No, I have no Medicare coverage
81. Do you have Medicaid? Medicaid is a state-run health insurance program for people whose income is below a
certain level.
E Yes
E No

B

82. Do you have any other health insurance coverage? (mark all that apply)
E Yes, a Medigap policy
E Yes, other private health insurance
E No, I have no other insurance

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***QUESTIONS ABOUT YOUR HEALTH BEHAVIORS***

83.

83a.

How often do you take aspirin?
E Every day
E Every other day

E Occasionally

E Never

If you take aspirin, do you take it to...(mark all that apply)
E Relieve Pain
E Reduce chance of heart attack or stroke

84. Have you ever smoked cigarettes?
E Yes, still smoking every day
E Yes, still smoking some days

E Other

E Yes, but no longer smoke at all
E No, never smoked (Go to #92)

85. If you used to smoke but no longer do so, about how long has it been since you last smoked cigarettes at all?
E Less than 1 month
E 6-12 months
E More than 5 years (Go to #92)
E 1-5 months
E 1-5 years
86. In the past 12 months have you stopped smoking for 1 day or longer because you were trying to quit smoking?
E Yes
E No
87. During the past 12 months has a VA doctor or other VA health care provider asked if you were interested in
stopping smoking?
E Yes
E No (Go to #90)
88. During the past 12 months were you treated for smoking within the VA?
E Yes
E No
89. If you were treated for smoking, where did you receive the majority of your treatment?
E VA primary care provider
E VA mental health care provider
E VA smoking cessation clinic or program
E Other VA provider or program
90. During the past 12 months what services were recommended or offered to you by VA providers or VA treatment
programs to help you stop smoking? (Mark all that apply)
E Self-help materials
E Individual counseling
E Nicotine replacement medication (patch, gum, nasal spray or inhaler)
E Group counseling
E Zyban, an antismoking medication (also called Bupropion or Welbutrin)
E Telephone counseling

B

91. During the past 12 months which of the following services did you actually use to help you stop smoking? (Mark all
that apply)
E Self-help materials
E Individual counseling
E Nicotine replacement medication (patch, gum, nasal spray or inhaler)
E Group counseling
E Zyban, an antismoking medication (also called Bupropion or Welbutrin)
E Telephone counseling

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92. How often did you have a drink containing alcohol in the past 12 months? Consider a "drink" to be a can or bottle
of beer, a glass of wine, a wine cooler, or one cocktail or a shot of hard liquor (like scotch, gin or vodka). Please
mark only one.
E Never (Go to #96)
E 2-4 times a month
E 4-5 times a week
E Monthly or less
E 2-3 times a week
E 6 or more times a week
93. How many drinks containing alcohol did you have on a typical day when you were drinking in the past 12 months?
E 0 drinks (Did not drink in the past 12 months) (Go to #96)
E 3-4 drinks
E 7-9 drinks
E 1-2 drinks
E 5-6 drinks
E 10 or more drinks
94. How often did you have 6 or more drinks on one occasion in the past 12 months?
E Never
E Less than monthly
E Monthly
E Weekly
E Daily or almost daily
95. In the past 12 months has a VA doctor or other VA health care provider advised you about your drinking (to drink
less or not to drink alcohol)?
E Yes
E No

***RELIGIOUS/SPIRITUAL NEEDS***

96. My religious/spiritual needs are an important part of my overall care.
E Yes
E No
E Not applicable
97. I was asked if I had any religious/spiritual needs during my stay.
E Yes
E No
E Not applicable
98. My religious/spiritual needs were appropriately assessed and addressed.
E Yes
E No
E Not applicable
99. Literature in keeping with my faith was offered to me.
E Yes
E No
E Not applicable

***OVERALL IMPRESSIONS OF THE FACILITY***

100. How would you rate the hospital building overall (e.g., attractiveness of facility appearance, quality of building
maintenance and upkeep)?
E Poor
E Fair
E Good
E Very Good
E Excellent
101. In terms of your satisfaction, how would you rate the convenience of the location of the facility?
E Poor
E Fair
E Good
E Very Good
E Excellent

B

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Your answers are important to help us improve VA care. Thank you for completing this questionnaire. Please
place the completed questionnaire in the envelope we sent you. No stamp is required.
Simply place the envelope in any mailbox and return the survey to:

OQP/Performance Analysis Center for Excellence
C/O National Research Corporation
P.O. Box 82660
Lincoln, NE 68501-2660

NOTE: If you have a specific question, issue, or need regarding your VA Care you have three ways to get an
answer:
1. If you prefer to get information by telephone, you can reach the following offices at these toll free numbers:
a. VA Benefits: 1-800-827-1000
b. Health Care Benefits: 1-877-222-8387
c. Telecommunications Device for the Deaf (TDD): 1-800-829-4833
2. If you prefer you can also get information via the internet from VA's home page on the World Wide Web on the
computer at www.va.gov. Veterans' benefits includes eligibility, compensation, education benefits, vocational
rehabilitation, home loan guaranty, Board of Veteran's Appeals, and other important information.
3. If your question is about a certain service at your local VA medical facility, please contact the local VA medical
center department that you think can best help you. If you are not sure whom to contact, you can call the Patient
Advocate in the VA where you get your care.

B

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