VA Form 10-0547 Cardiac Cath Lab Customer Satisfaction Survey

OMB 2900-XXXX
Estimated Burden: 8 minutes

Expiration Date: XX/XX/XXXX

Department of Veterans Affairs

Cardiac Cath Lab Patient Satisfaction Survey

Oklahoma City VA Hospital Cardiac Cath Lab Services

PRA Statement: 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 consent form will average 8 minutes. This includes the time it will take to read information provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

SHARE YOUR OPINIONS

We want your help! Your answers to the following questions will be a critical part of the service quality and improvement for our department. We continue to strive for excellence when providing your medical care, so your honest responses are appreciated. The information that you provide will be completely anonymous. We would like for you to “RATE” your most recent experience in our Cath Lab by CIRCLING your level of SATISFACTION. We appreciate your assistance and THANK YOU AGAIN!

PLEASE “CIRCLE” YOUR RESONSE

Gender Age Are You? Race/Ethnicity

Male 31-40 A new patient White/Caucasian

Female 41-50 A return patient Black/African American

51-60 Asian

61 - 70 American Indian or Alaskan Native

Over 70 Native Hawaiian or other Pacific Islander

Hispanic or Latino? yes / no

Length of Travel Length of Wait

For Procedure Today for Procedure Branch of Service

Less than 50 miles less than 2 weeks Army

50-100 miles 2 - 3 weeks Navy

100-200 miles 3 - 4 weeks Air Force

200-300 miles 4 - 5 weeks Marine

300-400 miles 5 – 6 weeks Coast Guard

More than 400 miles Over 6 weeks National Guard/Reserve

SURVEY ON BACK

BEFORE YOUR PROCEDURE

PLEASE “CIRCLE” YOUR LEVEL OF SATISFACTION

Question

Completely Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Completely Dissatisfied

Distance from parking lot to the lobby	1	2	3	4	5
Ease of check in to the window in E module	1	2	3	4	5
Your wait time in the lobby	1	2	3	4	5
Friendliness of staff greeting you	1	2	3	4	5
Education/ Information given to you and your family	1	2	3	4	5
Opportunity to ask questions	1	2	3	4	5

PREPARING YOU IN OUR HOLDING AREA

PLEASE “CIRCLE” YOUR LEVEL OF SATISFACTION

Question

Completely Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Completely Dissatisfied

Instructions on undressing and gowning	1	2	3	4	5
Level of Privacy	1	2	3	4	5
Level of Comfort	1	2	3	4	5
Informed consent/ explanation of your procedure	1	2	3	4	5
Opportunity to meet the physician	1	2	3	4	5
Cleanliness of holding area	1	2	3	4	5
Opportunity to see your family before the procedure	1	2	3	4	5

DURING YOUR PROCEDURE

PLEASE “CIRCLE” YOUR LEVEL OF SATISFACTION

Question

Completely Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Completely Dissatisfied

Temperature of the room	1	2	3	4	5
Cleanliness of the room	1	2	3	4	5
Explanation while preparing you on the procedure table.	1	2	3	4	5
Your level of comfort with the medication we gave you.	1	2	3	4	5
Level of attention you received	1	2	3	4	5
Level of professionalism of the nurses	1	2	3	4	5
Level of professionalism of the physicians	1	2	3	4	5
Length of the procedure	1	2	3	4	5

KEEP GOING YOU’RE ALMOST DONE!

AFTER YOUR PROCEDURE

PLEASE “CIRCLE” YOUR LEVEL OF SATISFACTION

Question

Completely Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Completely Dissatisfied

Physician explanation of results of procedure	1	2	3	4	5
Staff response to your questions	1	2	3	4	5
Courtesy and respect you were given	1	2	3	4	5
Explanation of follow up or other options to treatment	1	2	3	4	5
Discharge information	1	2	3	4	5
Level of pain upon discharge	1	2	3	4	5
Opportunity to visit family and friends	1	2	3	4	5
Overall satisfaction of procedure from start to finish	1	2	3	4	5

OPTIONAL:

If you could change anything, what would you do to improve Cath Lab services for patients?

What did you like least about the procedure?

What did you like most about the procedure?

(PLEASE CIRCLE ONE)

Would you recommend the Nursing Staff to other Veterans? YES NO

Would you recommend the Physicians to other Veterans? YES NO

Would you recommend this Cath Lab to other Veterans? YES NO

THANK YOU FOR YOUR PARTICIPATION!

VA Form 10-0547
MAY 2012

7