Form VA Form 10-0515 VA Form 10-0515 Spinal Cord Injury Patient Survey

OMB Number 2900-0770

Estimated Burden:  10 minutes

Expiration Date: XX/XX/XXXX

Patient Satisfaction (SCISC Rehabilitation)

Spinal Cord Injury Patient Care Survey

(Discharge)

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to take 10 minutes to complete survey, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 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.

Please mark the appropriate box for each question.

After completing this survey, please place it in the box at the nurses’ station. Rehabilitation Patients ONLY: return in the enclosed self addressed, stamped envelope. Thank you

Discharge date:

1. I was admitted to the SCI/D center for

1a. (New Injury/Rehab) 1b. Medical Problem 1c. Respite Program

1d. Annual Check-up 1e. Surgical Problem 1f. Other

2. My home SCI clinic is (mark one):

San Diego		Las Vegas		Loma Linda
Tucson		Phoenix		Other:

Questions	Poor	Fair	Good	Very good	Excellent	Does not apply
Admission
1. How would you rate the admission process.
Discharge Instructions
2. How clearly and completely you were told what to do and what to expect when you left the hospital.
3. Time it took to be discharged from the hospital and how efficiently it was handled.
SCI Team
4. Willingness of hospital staff to answer your questions.
5. Sensitivity of hospital staff to your special problems or concerns.
6. In terms of your satisfaction, how would you rate the doctor's personal manner (courtesy, respect, sensitivity, friendliness)?
7. Amount of information you were given about what to do after leaving the hospital.
8. The nurse or Physician Assistant showed me how to do things I will need to do at home.
9. Thinking about your most recent hospital stay, how would you rate how often doctors checked on you to keep track of how you were doing?
Occupational Therapist (OT)
10. If you saw occupational therapy during your stay, how would you rate the service?

Questions	Poor	Fair	Good	Very good	Excellent	Does not apply
Physical Therapists (PT)
11. If you saw physical therapy during this hospital stay, how would you rate the quality of the services you received?
Housekeeping Staff
12. How well they did their jobs and how they acted towards you.(Physical environment )
Nurses
13. Thinking about your most recent hospital stay, how would you rate how often nurses checked on you to keep track of how you were doing?
	Strongly agree	Agree	No opinion	Disagree	Strongly disagree
14. The nurse explains things in simple language.
15. The nurse always gives complete explanations of why tests are ordered.
16. The information given by the nurse about my physical problems helps me to adjust to my condition.
17. The nurse discusses how my condition will affect the sexual aspects of my life.
Physician and Physician's Assistant
18. Think about the care you receive from the usual source of care. Your doctor explains your medical problems to you.
Pharmacist
19. My pharmacist explained things thoroughly.
20. My pharmacist and I really talked about my prescriptions.
Questions	Strongly agree	Agree	No opinion	Disagree	Strongly disagree
Psychologist
21. If you met with the psychologist during your stay, did you feel he/she was supportive of your concerns?
Therapeutic Recreation (TR)
22. My recreation and leisure needs and concerns were addressed.
Vocational Rehabilitation Counselor
23. The Vocational Rehabilitation counselor was available to provide me with information and guidance about work and volunteer opportunities.
Personal Care Attendant (PCA) Coordinator
24. I was provided information on how to recruit, hire and supervise PCA’s.
Dietitian
25. The dietitian explained and taught me about my special dietary needs.
Social Worker	Yes Completely	Yes Somewhat	No	Did not see a Social worker
26. If there was a social worker involved in your care, did you feel that he/she helped smooth your transition from hospital to home?
Pain	Yes	No
27. Do you feel that more should have been done by the health care team to keep you free from pain during your last VA admission?
28. For symptoms other than pain (such as nausea or shortness of breath), do you feel that more should have been done to keep (PATIENT) comfortable during (PATIENT'S) last VA inpatient admission?
Discharge Instructions (continued)
29. Before you were discharged, did someone review your medication and how to take it?
Questions	same day	2-7 days	8-14 days	>21 days	Still waiting to be resolved	Did not report any complaints
Patient advocate/Complaint Resolution
3 31. Is there anything else that you would like to share about how the care could have been improved for you? 0. How long did it take for the VA hospital to resolve your complaint?

VA Form 10-0515
April 2012