Form 10-0515 Spinal Cord Injury Patient Care Survey

OMB Number 2900-0770

Estimated Burden:  10 minutes

Patient Satisfaction Questionnaire

Spinal Cord Injury Patient Care Survey

(Discharge)

OMB No. 2900-0770
Estimated Burden: 10 minutes

Expiration Date: 9/30/2020

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 the 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 circle the appropriate answer for each question or statement. If you did not use the service or see the person listed in the question, then please circle “Does not apply”.

After completing this survey, please place it in the survey box at the nurses’ station.

Rehabilitation Patients ONLY: return in the enclosed self-addressed, stamped envelope.

Month and Year of Discharge:

I was admitted to the SCI/D center for (circle all that apply)

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

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

My home SCI clinic is (circle one):

San Diego Las Vegas Loma Linda

Tucson Phoenix Other (please specify):

Admission

1. How would you rate the admission process?

Poor

Fair

Good

Very Good

Excellent

Does not apply

Discharge Instructions

2. How clearly and completely you were told what to do and what to expect when you left the hospital.

Poor

Fair

Good

Very Good

Excellent

Does not apply

3. Time it took to be discharged from the hospital and how efficiently it was handled.

Poor

Fair

Good

Very Good

Excellent

Does not apply

SCI Team

4. Willingness of hospital staff to answer your questions.

Poor

Fair

Good

Very Good

Excellent

Does not apply

5. Sensitivity of hospital staff to your special problems or concerns.

Poor

Fair

Good

Very Good

Excellent

Does not apply

6. In terms of your satisfaction, how would you rate the doctor's personal manner (courtesy, respect, sensitivity, friendliness)?

Poor

Fair

Good

Very Good

Excellent

Does not apply

7. Amount of information you were given about what to do after leaving the hospital.

Poor

Fair

Good

Very Good

Excellent

Does not apply

SCI Team (cont)

8. The nurse or Physician Assistant showed me how to do things I will need to do at home.

Poor

Fair

Good

Very Good

Excellent

Does not apply

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?

Poor

Fair

Good

Very Good

Excellent

Does not apply

Occupational Therapist

10. If you attended occupational therapy, how would you rate the occupational therapy service?

Poor

Fair

Good

Very Good

Excellent

Does not apply

Physical Therapists (PT)

11. If you attended physical therapy, how would you rate the quality of the physical therapist (PT) services you received?

Poor

Fair

Good

Very Good

Excellent

Does not apply

Housekeeping Staff

12. How well did the housekeeping staff do their jobs and how did they act towards you? (Physical environment)

Poor

Fair

Good

Very Good

Excellent

Does not apply

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?

Poor

Fair

Good

Very Good

Excellent

Does not apply

14. The nurse explained things in simple language.

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

15. The nurse always gave complete explanations of why tests, if any, were ordered.

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

16. The information given by the nurse about my physical problems helped me to adjust to my condition.

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

17. The nurse discussed how my condition will affect the sexual aspects of my life.

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

Physician and Physician's Assistant

18. The doctor or physician’s assistant explained my medical problems to me.

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

Pharmacist

19. If you saw the pharmacist, did the pharmacist explain things thoroughly?

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

20. My pharmacist and I really talked about my prescriptions.

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

Psychologist

21. If you saw a psychologist, was he/she supportive of your concerns?

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

Therapeutic Recreation (TR)

22. My recreation and leisure needs and concerns were addressed.

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

Vocational Rehabilitation Counselor

23. If you saw the Vocational Rehabilitation Counselor, was the Vocational Rehabilitation counselor able to provide information and guidance about work and volunteer opportunities?

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

Personal Care Attendant (PCA) Coordinator

24. I was provided information on how to recruit, hire and supervise personal care attendants (PCA’s).

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

Dietitian

25. If you saw a dietitian, did the dietitian explain and teach you about your special dietary needs?

Strongly disagree

Disagree

No opinion

Agree

Strongly agree

Does not apply

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?

Yes completely

Yes somewhat

No

Did not see a social worker

Pain

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?

Yes completely

Yes somewhat

No

Does not apply

28. For symptoms other than pain (such as nausea or shortness of breath), do you feel that more should have been done to keep you comfortable during your last VA admission?

Yes completely

Yes somewhat

No

Does not apply

Discharge Instructions (continued)

29. Before you were discharged, did someone review your medication and how to take it?

Yes completely

Yes somewhat

No

Does not apply

Patient Advocate/Complaint Resolution

30. If you made a formal complaint, how long did it take for the VA hospital to resolve your complaint? (If no complaints, mark “Did not file a complaint.”)

Same day

2-7 days

8-21 days

> 21 days

Still waiting to be resolved

Did not file a complaint

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

VA Form 10-0515

May 2015, rev 6

5 of 5