10-1465-3 SHEP Outpatient_Long Form_10-1465-3

Outpatient Long Form September 19, 2007

OMB Number 2900-XXXX

Est. Burden: 25 minutes

VA Form 10-1465-3

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
AMBULATORY CARE 2007

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 will help ensure that all veterans receive the high 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 25 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as customer expectations and desires. 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.

SURVEY INSTRUCTIONS

• You should only fill out this survey if you were the patient named in the cover letter. Do not fill out this survey if you were not the patient.

• Answer all the questions by checking the box to the left of your answer.

• You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

 Yes

 No  If No, Go to Question 1 on Page 1

You may notice a number on the cover of this survey. This number is ONLY used to let us know if you returned your survey so we don't have to send you reminders.

your last visit to a va clinic

1. What was the reason for your most recent clinic visit? (You may choose more than one)

• Routine physical

• Routine follow-up

• Flare-up of a long-term problem

• Get help with a new problem

• Prescription refill

• Other

2. On the day of your appointment, how long did you wait in line to check in?

• No wait

• 1 to 10 minutes

• 11 to 20 minutes

• 21 to 30 minutes

• 31 to 60 minutes

• More than 1 hour

• Can't remember

3. How long after the time when your appointment was scheduled to begin did you wait to be seen?

• No wait

• 1 to 10 minutes

• 11 to 20 minutes

• 21 to 30 minutes

• 31 to 60 minutes

• More than 1 hour

• Can’t remember

4. Was the provider willing to talk to your family or friends about your health or treatment?

• Yes

• No

• No family/friends involved

5. Did you have concerns that you wanted to discuss but did not?

• Yes

• No

The following questions will help us understand your opinion regarding some characteristics of the VA facility at which you received your medical care:

6. Examination/Treatment Room:

	Poor	Fair	Good	Very Good	Excellent	Does Not Apply
a. Cleanliness of the room						
b. Privacy while in the room						
c. Noise level						
d. Sense of safety and security						

7. Equipment and Facilities:

	Poor	Fair	Good	Very Good	Excellent	Does Not Apply
a. Cleanliness of the reception/waiting area						
b. Cleanliness of the restroom/lavatory						
c. Availability of parking						

8. Equipment and Facilities (continued):

	Poor	Fair	Good	Very Good	Excellent	Does Not Apply
a. How would you rate the clinic building overall (i.e., attractiveness of facility appearance, quality of building maintenance and upkeep)?						
b. In terms of your satisfaction, how would you rate the convenience of the location of the clinic facility?						

YOUR HEALTHCARE AT THIS CLINIC OVER THE PAST 12 MONTHS

Please think about all of the healthcare you received at your last clinic visit and any other visits to this same clinic in the past 12 months.

9. In the last 12 months, did providers at this clinic give you complete and accurate information about:

	Yes	No	Does Not Apply
a) Tests?			
b) Choices for your care?			
c) Treatment?			
d) Plan for your care?			
e) Medications?			
f) Follow-up care?			
g) Side effects of medications?			

YOUR PERSONAL
DOCTOR OR NURSE

10. A personal doctor or nurse is the health provider who knows you best. This can be a general doctor, a specialist doctor, a nurse practitioner, or a physician assistant. Do you have one person you think of as your personal doctor or nurse?

• Yes

• No  If No, Go to Question 20

11. In the last 12 months, how many times did you visit your personal doctor or nurse to get care for yourself?

• None  If None, Go to Question 19

• 1

• 2

• 3

• 4

• 5 to 9

• 10 or more

12. In the last 12 months, how often did your personal doctor or nurse explain things in a way that was easy to understand?

• Never

• Sometimes

• Usually

• Always

13. In the last 12 months, how often did your personal doctor or nurse listen carefully to you?

• Never

• Sometimes

• Usually

• Always

14. In the last 12 months, how often did your personal doctor or nurse show respect for what you had to say?

• Never

• Sometimes

• Usually

• Always

15. In the last 12 months, how often did your personal doctor or nurse spend enough time with you?

• Never

• Sometimes

• Usually

• Always

16. In the last 12 months, did you feel this doctor or nurse really cared about you as a person?

• Yes

• No

17. In the last 12 months, did you get care from a doctor or other health provider besides your personal doctor or nurse?

• Yes

• No  If No, Go to Question 19

18. In the last 12 months, how often did your personal doctor or nurse seem informed and up-to-date about the care you got from these doctors or other health providers?

• Never

• Sometimes

• Usually

• Always

19. Using any number from 0 to 10, where 0 is the worst personal doctor or nurse possible and 10 is the best personal doctor or nurse possible, what number would you use to rate your personal doctor or nurse?

• 0 Worst personal doctor/nurse possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 Best personal doctor/nurse possible

Using the VA Pharmacy
During the Past 2 Months

20. How long did you usually wait for your prescriptions to be filled at the VA pharmacy?

• 1 to 10 minutes

• 11 to 20 minutes

• 21 to 30 minutes

• 31 to 40 minutes

• More than 40 minutes

• Did not wait at the VA pharmacy; I had my prescriptions mailed to me

• Didn’t use the VA pharmacy during the past 2 months  If Didn’t Use, Go to Question 25

21. Have you had any concerns about VA pharmacy services during the past 2 months?

• Yes

• No  If No, Go to Question 24

22. What were your concerns about VA pharmacy services during the past 2 months? (Please mark all that apply)

• I received the wrong medication through the mail out program.

• I received the wrong medication at the VA pharmacy pick up window.

• I received too large a supply of one or more medications through the mail out program.

• I received too large a supply of one or more medications through the VA pharmacy pick up window.

• There was an unexplained changed to the medication I received through the mail out program.

• There was an unexplained change to the medication I received through the VA pharmacy pick up window.

23. If you had any of the concerns listed above, did you know whom to contact?

• Yes, and it was resolved

• Yes, but it was not resolved

• No, I did not know whom to contact

24. Overall, how would you rate VA pharmacy services during the past 2 months?

• Poor

• Fair

• Good

• Very good

• Excellent

Complaints about
VA healthcare

25. Did you have a complaint about how you were treated (medically or personally) during your last healthcare visit?

• Yes

• No  If No, Go to Question 31

26. If you reported this complaint to someone at the VA location where you received your care, to whom did you report this complaint?

• Treatment team  Skip to Question 28

• Other VA staff  Skip to Question 28

• Patient advocate  Skip to Question 28

• Did not report the complaint to a VA employee

27. If you did not report this complaint, what was the most important reason you did not report it? (Please mark only one)

• I did report the complaint

• I didn't know where to complain

• I was afraid of what would happen if I did complain

• I thought complaining wouldn't do any good

• I wasn't sure I had the right to complain

• Other

28. If you had a complaint, how easy was it for you to find someone to hear your complaint?

• Very easy

• Easy

• Difficult

• Very difficult

• Not applicable

29. If you spoke with someone at the VA location about a complaint, how satisfied were you with the way your complaint was handled?

• Very satisfied

• Satisfied

• Dissatisfied

• Very dissatisfied

• Not applicable

30. How long did it take for the VA hospital to resolve your complaint?

• Same day

• 2-7 days

• 8-14 days

• 15-21 days

• More than 21 days

• Complaint is not resolved

• Not applicable

Your Healthcare over
the past 12 months

Please think about all of the healthcare you received from the VA in the past 12 months.

31. In the last 12 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

• Yes

• No  If No, Go to Question 34

32. In the last 12 months, when you needed care right away, how often did you get care as soon as you thought you needed?

• Never

• Sometimes

• Usually

• Always

33. How long did it take to get the help you needed?

• No wait

• Within 1 hour

• More than 1 hour, but within 24 hours

• Greater than 24 hours

• Never got the help I wanted

34. In the last 12 months, not counting the times you went to an emergency room, how many times did you go to a clinic to get healthcare for yourself?

• None  If None, Go to Question 49

• 1

• 2

• 3

• 4

• 5 to 9

• 10 or more

35. In the last 12 months, not counting the times you needed care right away, did you make any appointments for your healthcare at a doctor’s office or clinic?

• Yes

• No  If No, Go to Question 37

36. In the past 12 months, not counting the times you needed care right away, how often did you get an appointment as soon as you thought you needed?

• Never

• Sometimes

• Usually

• Always

37. In the last 12 months, how often did staff at a VA doctor’s office or clinic treat you with courtesy and respect?

• Never

• Sometimes

• Usually

• Always

38. Was personal information about you treated in a confidential manner?

• Yes, always

• Yes, sometimes

• No

39. Were there times when you were confused because different providers told you different things?

• Yes

• No

40. Did you know whom to ask when you had questions about your healthcare?

• Yes

• No

41. Choices for your treatment or healthcare can include choices about medicine, surgery, or other treatment. In the last 12 months, did a doctor or other health provider tell you there was more than one choice for your treatment or healthcare?

• Yes

• No  If No, Go to Question 44

42. In the last 12 months, did a doctor or other health provider talk with you about the pros and cons of each choice for your treatment or healthcare?

• Definitely

• Somewhat yes

• Somewhat no

• Definitely no

43. In the last 12 months, when there was more than one choice for your treatment or healthcare, did a doctor or other health provider ask which choice was best for you?

• Definitely yes

• Somewhat yes

• Somewhat no

• Definitely no

44. In the last 12 months, how often did you have a hard time speaking with or understanding your doctors or other health providers because you spoke different languages?

• Never

• Sometimes

• Usually

• Always

45. In the last 12 months, how often did you and a doctor or other health provider talk about specific things you could do to prevent illness?

• Never

• Sometimes

• Usually

• Always

46. Using any number from 0 to 10, where 0 is the worst healthcare possible and 10 is the best healthcare possible, what number would you use to rate all your healthcare in the last 12 months?

• 0 Worst healthcare possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 Best healthcare possible

47. In the past 12 months, did you try to get any care, tests or treatment through VA?

• Yes

• No  If No, Go to Question 49

48. In the past 12 months, how often was it easy to get the care, tests or treatment you thought you needed through VA?

• Never

• Sometimes

• Usually

• Always

About your experience
with specialists

49. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of healthcare. In the last 12 months, did you try to make any appointments to see a specialist?

• Yes

• No  If No, Go to Question 51

50. In the last 12 months, how often was it easy to get appointments with specialists?

• Never

• Sometimes

• Usually

• Always

51. In the last 12 months, did you see a specialist?

• Yes

• No  If No, Go to Question 57

52. Please think about your most recent specialist visit. What kind of specialist visit was it?

• First time visit with this type of specialist

• Repeat visit with this type of specialist

53. Was this specialist:

• A VA specialist

• A non-VA specialist referred by a VA provider

• A non-VA specialist seen on my own  If Non-VA Specialist Seen on My Own, Go to Question 57

54. How long did you wait between the time you were told you needed to see this specialist and the day you actually saw the specialist?

• Same day

• 1 to 14 days

• 15 to 30 days

• 31 to 60 days (1 to 2 months)

• 61 to 120 days (2 to 4 months)

• More than 120 days (over 4 months)

55. In the last 12 months, how often did the specialists you saw seem to know the important information about your medical history?

• Never

• Sometimes

• Usually

• Always

56. We want to know your rating of the specialist you saw most often in the last 12 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?

• 0 Worst specialist possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 Best specialist possible

About your overall experience with VA healthcare

57. If you could have free care outside the VA, would you choose to come here again?

• Definitely would not

• Probably would not

• Probably would

• Definitely would

58. All things considered, how satisfied are you with your healthcare in the VA?

• Completely satisfied

• Very satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Very dissatisfied

• Completely dissatisfied

ABOUT YOUR HEALTH

59.    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?

¹   Yes, Limited A Lot

²   Yes, Limited A Little

³   No, Not Limited At All

b. Climbing several flights of stairs?

¹   Yes, Limited A Lot

²   Yes, Limited A Little

³   No, Not Limited At All

60.    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?

¹   No, none of the time

²   Yes, a little of the time

³   Yes, some of the time

⁴   Yes, most of the time

⁵   Yes, all of the time

b. Were limited in the kind of work or other activities?

¹   No, none of the time

²   Yes, a little of the time

³   Yes, some of the time

⁴   Yes, most of the time

⁵   Yes, all of the time

61.    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

¹   No, none of the time

²   Yes, a little of the time

³   Yes, some of the time

⁴   Yes, most of the time

⁵   Yes, all of the time

b. Didn't do work or other activities as carefully as usual

¹   No, none of the time

²   Yes, a little of the time

³   Yes, some of the time

⁴   Yes, most of the time

⁵   Yes, all of the time

62.    During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

¹   Not at all

²   A little bit

³   Moderately

⁴   Quite a bit

⁵   Extremely

63. How much of the time during the past 4 weeks:

	All of the time	Most of the time	A good bit of the time	Some of the time	A little of the time	None of the time
a. Have you felt calm and peaceful?						
b. Did you have a lot of energy?						
c. Have you felt downhearted and blue?						

64.    How much of the time during the past 4 weeks has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

¹   All of the time

²   Most of the time

³   Some of the time

⁴   A little of the time

⁵   None of the time

65.   Compared to one year ago, how would you rate your physical health in general now?

¹   Much better

²   Somewhat better

³   About the same

⁴   Somewhat worse

⁵   Much worse

66.   Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?

¹   Much better

²   Somewhat better

³   About the same

⁴   Somewhat worse

⁵   Much worse

67.   How much of the time during the past week, did you feel depressed?

¹   Rarely or none of the time (less than 1 day)

²   Some or a little of the time (1-2 days)

³   Occasionally or a moderate amount of the time (3-4 days)

⁴   Most or all of the time (5-7 days)

68.   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?

¹   Yes

²   No 

69.   Have you had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes?

¹   Yes

²   No 

70.    Have you been treated by a VA provider for chronic pain in the past 12 months?

¹   Yes

²   No 

71.   If you have been treated by a VA provider for chronic pain, please rate the effectiveness of your pain treatment?

¹   Poor

²   Fair

³   Good

⁴   Very good

⁴   Excellent

72.    Do you now smoke every day, some days, or not at all?

¹   Every day

²   Some days

³   Not at all, have not smoked more than 100 cigarettes in entire life

⁴   Not at all currently, but smoked previously

⁴   Do not know

73.    How long has it been since you stopped smoking cigarettes?

¹   12 months or less

²   More than 12 months

³   Do not know

74.    In the past 12 months, on how many visits were you advised to quit smoking by a VA doctor or other VA health provider?

¹   None

²   1 visit

³   2 to 4 visits

⁴   5 to 9 visits

⁵   10 or more visits

⁶   I had no visits in the last 12 months.

75.    On how many visits was medication recommended or discussed to assist you with quitting smoking (for example: nicotine gum, patch, nasal spray, inhaler, prescription medication)?

¹   None

²   1 visit

³   2 to 4 visits

⁴   5 to 9 visits

⁵   10 or more visits

⁶   I had no visits in the last 12 months.

76.    On how many visits did your VA doctor or VA health provider recommend or discuss methods and strategies (other than medication) to assist you with quitting smoking?

¹   None

²   1 visit

³   2 to 4 visits

⁴   5 to 9 visits

⁵   10 or more visits

⁶   I had no visits in the last 12 months.

⁴   Individual counseling

⁵   Group counseling

⁶   Telephone counseling

77.    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.

¹   Never Go to 81.

²   Monthly or less

³   2-4 times a month

⁴   2-3 times a week

⁵   4-5 times a week

⁶   6 or more times a week

78.    How many drinks containing alcohol did you have on a typical day when you were drinking in the past 12 months?

¹   0 drinks (Did not drink in the past 12 months) Go to 81.

²   1-2 drinks

³   3-4 drinks

⁴   5-6 drinks

⁵   7-9 drinks

⁶   10 or more drinks

79.    How often did you have 6 or more drinks on one occasion in the past 12 months?

¹   Never

²   Less than monthly

³   Monthly

⁴   Weekly

⁵   Daily or almost daily

80.    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)?

¹   Yes

²   No 

81.    Did you get a flu vaccine in September 2006 or later? (Please mark only one)

¹   Yes, Flu Shot (Go to #105)

²   Yes, FluMist (a flu vaccine sprayed into the nose)  (Go to #105)

²   No

82.     If you did not get a flu vaccine in September 2006 or later, why not? Mark the MAIN reason:

¹   was told I was not eligible to get the flu vaccine this year because of the shortage

²   Flu vaccine not available and I didn't get it elsewhere

³   Medical advice not to get a flu shot (such as allergy, illness)

⁴   No time/Didn't get around to it

⁵   Inconvenient to get it at the VA

⁶   Don't like needles/injections

⁷   I believe it might make me sick

⁸   Don't believe in it/Prefer other methods of prevention

⁹   Did not think I needed a flu shot

¹⁰   Did not want a flu vaccine

¹¹   I plan to get my flu vaccine at a later date

¹²   Other

83.     Where did you get your flu vaccine?

¹   At the VA (such as a hospital, clinic, outreach mobile unit)

²   Vet Center

³   Non-VA hospital, clinic, doctor's office, visiting nurse or Health Department

⁴   Community source (drug store, church, grocery store, etc.)

⁵   Other

⁶   Do not remember

84.     The pneumonia vaccine (Pneumovax) is recommended for certain age groups or medical conditions. It is usually only needed once in your lifetime. Have you ever had a pneumonia vaccination?

¹   Yes

²   No

³   Do not know

About You

85. In general, how would you rate your overall health?

• Excellent

• Very good

• Good

• Fair

• Poor

86. Are you of Spanish, Hispanic or Latino origin or descent?

• No, not Spanish/Hispanic/Latino

• Yes, Puerto Rican

• Yes, Mexican, Mexican American, Chicano

• Yes, Cuban

• Yes, other Spanish/Hispanic/Latino

87. What is your race? (Mark all that apply)

• White

• Black or African American

• Asian

• Native Hawaiian or Pacific Islander

• American Indian or Alaska Native

88. What is the last year of school you have completed?

• Did not complete high school

• High school graduate or GED

• Some college

• College graduate or beyond

If you have a specific question or need help with your VA care, you may contact the VA:

1. By telephone:

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. Information on a broad range of veterans' benefits is available on our home page at

www.va.gov.

3. At your local VA medical center. Either contact the department that you think can help

you or ask for the Patient Advocate.

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/SHEP Surveys

C/OSynovate Corporation

P.O. Box ???

Chicago, IL Zip