VA Form 10-1465-2 HCAHPS SHEP Core Short Form 10-1465-2

HCAHPS plus Inpatient Core_Short form
OMB Number 2900-0712
Est. Burden: 15 minutes
VA Form 10-1465-2

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
RECENTLY DISCHARGED INPATIENT 2009
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 15 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 nonidentifying 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.

-

HCAHPS plus Inpatient Core_Short form
SURVEY INSTRUCTIONS

♦
♦
♦

You should only fill out this survey if you were the patient during the hospital stay
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

Î 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.
Please note: Questions 1-22 in this survey are part of a national initiative to measure
the quality of care in hospitals.

Please answer the questions in this survey about your stay at the hospital named on
the cover. Do not include any other hospital stay in your answers.

YOUR CARE FROM NURSES
1.

4.

During this hospital stay, how often did
nurses treat you with courtesy and
respect?

† Never
† Sometimes
3
† Usually
4
† Always
5
† I never pressed the call button
1

† Never
† Sometimes
3
† Usually
4
† Always
1

2

2

2.

During this hospital stay, how often did
nurses listen carefully to you?

† Never
† Sometimes
3
† Usually
4
† Always
1
2

3.

During this hospital stay, how often did
nurses explain things in a way you could
understand?

† Never
† Sometimes
3
† Usually
4
† Always
1
2

-

During this hospital stay, after you
pressed the call button, how often did
you get help as soon as you wanted it?

YOUR CARE FROM DOCTORS
5.

During this hospital stay, how often did
doctors treat you with courtesy and
respect?

† Never
† Sometimes
3
† Usually
4
† Always
1
2

HCAHPS plus Inpatient Core_Short form
6.

1

How often did you get help in getting to
the bathroom or in using a bedpan as
soon as you wanted?

2

1

During this hospital stay, how often did
doctors listen carefully to you?

11.

† Never
† Sometimes
3
† Usually
4
† Always
7.

During this hospital stay, how often did
doctors explain things in a way you
could understand?

† Never
2
† Sometimes
3
† Usually
4
† Always

† Never
† Sometimes
3
† Usually
4
† Always
2

12.

1

1

13.

† Never
† Sometimes
3
† Usually
4
† Always

† Never
† Sometimes
3
† Usually
4
† Always
2

14.

2

9.

† Never
2
† Sometimes
3
† Usually
4
† Always
YOUR EXPERIENCES IN THIS
HOSPITAL
10.

During this hospital stay, did you need
help from nurses or other hospital staff
in getting to the bathroom or in using a
bedpan?
1

† Yes
† No Î If No, Go to Question 12

2

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During this hospital stay, how often did
the hospital staff do everything they
could to help you with your pain?

† Never
† Sometimes
3
† Usually
4
† Always
1
2

During this hospital stay, how often was
the area around your room quiet at
night?
1

During this hospital stay, how often was
your pain well controlled?
1

During this hospital stay, how often
were your room and bathroom kept
clean?
1

† Yes
† No Î If No, Go to Question 15

2

THE HOSPITAL ENVIRONMENT
8.

During this hospital stay, did you need
medicine for pain?

15.

During this hospital stay, were you
given any medicine that you had not
taken before?
1

† Yes
† No Î If No, Go to Question 18

2

16.

Before giving you any new medicine,
how often did hospital staff tell you
what the medicine was for?

† Never
† Sometimes
3
† Usually
4
† Always
1
2

HCAHPS plus Inpatient Core_Short form

17.

Before giving you any new medicine,
how often did hospital staff describe
possible side effects in a way you could
understand?

† Never
† Sometimes
3
† Usually
4
† Always

OVERALL RATING OF HOSPITAL
Please answer the following questions about
your stay at the hospital named on the cover.
Do not include any other hospital stays in
your answer.

1
2

21. Using any number from 0 to 10, where 0
is the worst hospital possible and 10 is
the best hospital possible, what number
would you use to rate this hospital
during your stay?

WHEN YOU LEFT THE HOSPITAL

†
†
2
†
3
†
4
†
5
†
6
†
7
†
8
†
9
†
10
†
0
1

18. After you left the hospital, did you go
directly to your own home, to someone
else’s home, or to another health
facility?

† Own home
† Someone else’s home
3
† Another health facility Î If Another,
1
2

Go to Question 21
19.

During this hospital stay, did doctors,
nurses or other hospital staff talk with
you about whether you would have the
help you needed when you left the
hospital?

22.

1
2

4 of 8

† Yes
† No

Best hospital possible

Would you recommend this hospital to
your friends and family?

† Definitely no
† Probably no
3
† Probably yes
4
† Definitely yes

† Yes
2
† No
During this hospital stay, did you get
information in writing about what
symptoms or health problems to look
out for after you left the hospital?

Worst hospital possible

1

1

20.

0
1
2
3
4
5
6
7
8
9
10

2

23.

During this hospital stay, how often was
personal information about you treated
in a confidential manner?

† Never
† Sometimes
3
† Usually
4
† Always
1
2

HCAHPS plus Inpatient Core_Short form

24.

During this hospital stay, how often did
nurses show respect for what you had to
say?

29.

† Never
† Sometimes
3
† Usually
4
† Always
1
2

25.

During this hospital stay, how often did
you feel nurses really cared about you
as a person?

† Never
† Sometimes
3
† Usually
4
† Always
1
2

30.

† Never
† Sometimes
3
† Usually
4
† Always
1
2

26.

During this hospital stay, how often did
doctors show respect for what you had
to say?

Yes

No

Does Not
Apply

1

†

2

†

3

†

b) Choices for your
care?

1

†

2

†

3

†

c) Treatment?

1

†

2

†

3

†

d) Plan for your care?

1

†

2

†

3

†

e) Medications?

1

†

2

†

3

†

During this hospital stay, how often did
you feel doctors really cared about you
as a person?

f) Follow-up care?

1

†

2

†

3

†

1

†

2

†

3

† Never
2
† Sometimes
3
† Usually
4
† Always

g) Side effects of
medications

†

31.

† Never
2
† Sometimes
3
† Usually
4
† Always

1

28.

During your most recent hospital stay,
did providers at this hospital give you
complete and accurate information
about:

a) Tests?

1

27.

During this hospital stay, how often did
you have a hard time speaking with or
understanding your doctors or other
health providers because you spoke
different languages?

During this hospital stay, were
providers willing to talk to your family
or friends about your health or
treatment?
1
2

5 of 8

† Yes
† No

If you could have free care outside the
VA, would you choose to be hospitalized
here again?

† Definitely would not
† Probably would not
3
† Probably would
4
† Definitely would
1
2

HCAHPS plus Inpatient Core_Short form

32.

During this hospital stay, how often did
health care providers seem informed
and up-to-date about the care you got
from other providers at the hospital?

† Never
† Sometimes
3
† Usually
4
† Always

38.

1

39.

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

† Yes, Always
† Yes, Sometimes
3
† No

† Yes
† No

2

1
2

Did you know who to contact if you
needed medical advice or help right
away, after you went home?

Did you have a complaint about how
you were treated (medically or
personally) during your last
hospitalization?
1
2

† Yes
† No ÆGo to Question 45

1
2

34.

40.

Did you know who to ask when you had
questions about your health care?

† Treatment Team
† Other VA Staff
3
† Patient Advocate
4
† Did not report the complaint to a
1
2

† Yes, Always
† Yes, Sometimes
3
† No
1
2

35.

During this hospital stay, when there
was more than one choice for your
treatment or health care, did providers
ask which choice you thought was best
for you?
1
2

36.

VA employee
41.

If you did not report this complaint,
what was the most important reason
you did not report it? (Please mark only
one)
1
† I didn't know where to complain
2
† I was afraid of what would happen if I
did complain
3
† I thought complaining wouldn't do any
good
4
† I wasn't sure I had the right to
complain
5
† Other

42.

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

† Yes
† No

During this hospital stay, did providers
talk with you about the pros and cons of
each choice for your treatment or health
care?
1
2

† Yes
† No

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

† Very easy
† Easy
3
† Difficult
4
† Very difficult
5
† Not Applicable
1

37. Did someone on the hospital staff tell
you what activities you could do after
you got home?
1
2

6 of 8

† Yes
† No

2

HCAHPS plus Inpatient Core_Short form

45.

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

How would you rate the hospital
building overall (e.g., attractiveness of
facility appearance, quality of building
maintenance and upkeep)?

†
†
3
†
4
†
5
†
1

† Very satisfied
2
† Satisfied
3
† Dissatisfied
4
† Very dissatisfied
5
† Not Applicable
1

2

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

46.

Poor
Fair
Good
Very good
Excellent

1

In terms of your satisfaction, how would
you rate the convenience of the location
of the facility?

2

1

† Same day
† 2-7 days
3
† 8-14 days
4
† 15-21 days
5
† More than 21 days
6
† Complaint is not resolved
47.

†
†
3
†
4
†
5
†
2

Poor
Fair
Good
Very good
Excellent

Your Room:
Poor

Fair

Good

Very
Good

Excellent

Does Not
Apply

a. Cleanliness of your room

1

†

2

†

3

†

4

†

5

†

6

†

b. Privacy of your room

1

†

2

†

3

†

4

†

5

†

6

†

c. Noise level

1

†

2

†

3

†

4

†

5

†

6

†

d. Sense of safety and security

1

†

2

†

3

†

4

†

5

†

6

†

48.

Equipment and Facilities:
Poor

a. Ease of finding your way around
the hospital
b. Availability of parking

7 of 8

Fair

Good

Very
Good

Excellent

Does Not
Apply

1

†

2

†

3

†

4

†

5

†

6

†

1

†

2

†

3

†

4

†

5

†

6

†

HCAHPS plus Inpatient Core_Short form

ABOUT YOU
There are only a few remaining items left.
49.

In general, how would you rate your
overall health?

1
2

† 8th grade or less
† Some high school, but did not

graduate
† High school graduate or GED
4
† Some college or 2-year degree
5
† 4-year college graduate
6
† More than 4-year college degree

† Excellent
2
† Very good
3
† Good
4
† Fair
5
† Poor
1

3

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

† No, not Spanish/Hispanic/Latino
† Yes, Puerto Rican
3
† Yes, Mexican, Mexican American,
1
2

Chicano
† Yes, Cuban
5
†Yes, other Spanish/Hispanic/Latino
4

51.

52. What is the highest grade or level of
school that you have completed?

53. What is your race? Please choose
one or more.

† White
† Black or African American
3
† Asian
4
† Native Hawaiian or other Pacific
1
2

5

Islander
† American Indian or Alaska Native

What language do you mainly speak
at home?

† English
† Spanish
8
† Some other language (please
1
2

print): _____________________
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

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