VA Form 10-0538 Purchased Care Patient Satisfaction Survey

OMB 2900-XXXX
Estimated Burden 12 minutes

Expiration Date: XX/XX/XXXX

Purchased Care Patient Satisfaction
Online Survey

Your answers to the following short questionnaire will help VA understand your satisfaction with the service you received when you were referred for specialty care outside of a VA facility.

Your answers and feedback are important to help us ensure the quality of health care service provided by non-VA providers, and all information is strictly private. Participating in this survey will not affect your usual VA care.

Select the box next to the response choice that best describes your experience. Please read each question and be sure to read all pages of this questionnaire.

Do not include any visits with a VA provider or care you received when you stayed overnight in a hospital in your answers.

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 12 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 improvement in the quality of service delivery by helping to shape the direction and focus of specific programs or services. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

P1 The following questions pertain to your recent visit with a non-VA provider on:

Seeing a Non-VA Specialist

Specialists are doctors like surgeons, heart doctors, foot doctors, and other doctors who specialize in one area of health care.

Q1 Please think about your non-VA specialist visit during the past 2 months. Was this non-VA specialist…?

A VA specialist

A non-VA specialist referred to by VA provider

A non-VA specialist seen on my own [not referred by a VA provider]

Didn’t have a specialist visit in the last 2 months

If your answer to the above question Q1 was “A VA specialist" or "Didn't have a specialist visit” (STOP!) you are finished with the survey. Thank you for your time! Please submit the survey in the postage-paid envelope provided.

Q2 The following statement refers to the access and convenience of clinic services: It was not

difficult to schedule the non-VA appointment.

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

Q3 How long did you wait between the time you were told you needed to see a specialist and the day you actually saw the non-VA 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)

Q4 In terms of your satisfaction, how would you rate how long you waited to get an appointment with the non-VA specialist?

Poor Fair Good

Very Good

Excellent

Does Not Apply

Q5 How long did it take you to travel to the facility where you had your visit?

Less than 10 minutes

10 minutes to less than 15 minutes

15 minutes to less than 30 minutes

30 minutes to an hour

More than 1 hour

Convenient Access to Non-VA Specialist

Q6 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

Q7 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

Q8 How would you rate the waiting time in the office or clinic to see the non-VA specialist?

Poor Fair Good

Very Good

Excellent

Does Not Apply

During the Visit

Q9 Was personal information about you treated in a confidential manner?

Yes, always Yes, sometimes No

Q10 Did the non-VA specialist you saw seem to know the important information about your medical history?

Yes

No

Q11 Did the non-VA specialist explain things in a way you could understand?

Yes

No

Q12 During your most recent office visit, how would you rate how well the non-VA specialist listened to you?

Poor Fair Good

Very Good

Excellent

Not Applicable

Q13 During your most recent office visit, how would you rate the courtesy and respect shown to you by the non-VA specialist?

Poor Fair Good

Very Good

Excellent

Does not apply

Q14 Did you have a complaint about how you were treated (medically or personally) during your last health care visit?

Yes

No (If No, Go to Question 16)

Q15 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

Q16 All things considered, how satisfied were you with the non-VA provider during your recent visit?

Completely satisfied Very satisfied Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied Very dissatisfied Completely dissatisfied

Q17 We want to know your rating of the non-VA specialist you saw during your recent visit. 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

Q18 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

rate the healthcare service you received from the non-VA specialist?

0 Worst healthcare possible

1

2

3

4

5

6

7

8

9

10 Best healthcare possible

Q19 How would you rate the following aspects of the examination or treatment room?

_{Poor Fair Good Very Good Excellent}

Does not apply

Cleanliness of the room Privacy while in the room Noise level

_{Sense of safety and security}

Q20 How would you rate the following aspects of the equipment and facilities?

_{Poor Fair Good Very Good Excellent}

Does not apply

Cleanliness of the reception/waiting area

Cleanliness of the restroom/lavatory

Availability of parking

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

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

General Questions

Q21 In general, how would you rate your overall health?

Excellent Very good Good

Fair

Poor

Q22 Are you of Hispanic or Latino origin or descent?

Yes, Hispanic or Latino

No, Not Hispanic or Latino

Q23 What is your race?

White

Black or African American

Asian

Native Hawaiian or Pacific Islander American Indian or Alaska Native

Q24 Did someone else help you complete this survey?

Yes

No, I completed it alone, without help

Q25 Is there anything else that you would like to share about how the care could have been improved?

Q26 For Internal Use Only:

Your answers are important to help us ensure the quality of health care service provided by non-VA specialists. Thank you for completing this questionnaire.

OMB 2900-XXXX

Estimated Burden: 12 min.

VA FORM 10-0538

NOVEMBER 2011