VA Form 10-1465-8 SHEP In-Center Hemodialysis (ICHemo) Long Form

OMB Number 2900-0712
Est. Burden: 16 minutes
VA Form 10-1465-8

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS: SHEP
2021 IN-CENTER HEMODIALYSIS
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 survey booklet. Your answers will
help ensure that all Veterans receive the high-quality care they have earned and so richly deserve.
Please read each question and check the box that best describes your experience. Please be sure to
read all pages of this survey booklet.
The check-box responses you provide to the survey questions will not be connected with you
personally but combined with the opinions of other Veterans before being reported. However, any
additional information which you provide including comments written in the margins, letters, and other
enclosures will be shared with the Medical Center Director or appropriate staff at your facility if it is the
best way to address your concerns, unless you indicate that you want your comments to remain
confidential and not be shared. If you would like to see the results of the survey for all Veterans who
get care at this facility, you may contact the Patient Advocate at this facility.
Participation is voluntary and your answers to the survey will not affect the health care you receive or
your eligibility for VA benefits.
If you have a specific question or need help with your VA care, you may contact the VA as described at
the end of this survey booklet.
Thank you very much!

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 16 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
non-identifying 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.

IPS_ICH_CAHPS_SVY_03.21

SURVEY INSTRUCTIONS
This survey is about your experiences with dialysis care at <>.
Answer each question by marking 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:



1.

Yes
No

If No, Go to Question 25

Where do you get your dialysis
treatments?

4.

At home or at a skilled nursing home
where I live If At home or at a
skilled nursing home where I live,
Go to Question 45
At the dialysis center
I do not currently receive dialysis
If I do not currently receive
dialysis, Go to Question 45
2.

Never
Sometimes
Usually
Always
5.

How long have you been getting
dialysis at <>?

In the last 3 months, how often did
your kidney doctors show respect for
what you had to say?
Never
Sometimes
Usually
Always

Less than 3 months If Less than
3 months, Go to Question 45
At least 3 months but less than 1 year
At least 1 year but less than 5 years
5 years or more
I do not currently receive dialysis at
this dialysis center If I do not
currently receive dialysis at this
dialysis center, Go to Question 45

6.

In the last 3 months, how often did
your kidney doctors spend enough
time with you?
Never
Sometimes
Usually
Always

YOUR KIDNEY DOCTORS
Your kidney doctors are the doctor or
doctors most involved in your dialysis care
now. This includes kidney doctors that you
see inside and outside the center.
3.

In the last 3 months, how often did
your kidney doctors explain things in a
way that was easy for you to
understand?

7.

In the last 3 months, how often did
your kidney doctors listen carefully to
you?

In the last 3 months, how often did you
feel your kidney doctors really cared
about you as a person?
Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always
2

IPS_ICH_CAHPS_SVY_03.21

8.

12. In the last 3 months, how often did the
dialysis center staff show respect for
what you had to say?

Using any number from 0 to 10, where
0 is the worst kidney doctors possible
and 10 is the best kidney doctors
possible, what number would you use
to rate the kidney doctors you have
now?

Never
Sometimes
Usually
Always

0 Worst kidney doctors possible
1
2
3
4
5
6
7
8
9
10 Best kidney doctors possible
9.

13. In the last 3 months, how often did the
dialysis center staff spend enough
time with you?
Never
Sometimes
Usually
Always
14. In the last 3 months, how often did you
feel the dialysis center staff really
cared about you as a person?

Do your kidney doctors seem informed
and up-to-date about the health care
you receive from other doctors?

Never
Sometimes
Usually
Always

Yes
No
THE DIALYSIS CENTER STAFF

15. In the last 3 months, how often did
dialysis center staff make you as
comfortable as possible during
dialysis?

For the next questions, dialysis center staff
does not include doctors. Dialysis center
staff means nurses, technicians, dietitians,
and social workers at this dialysis center.

Never
Sometimes
Usually
Always

10. In the last 3 months, how often did the
dialysis center staff listen carefully to
you?

16. In the last 3 months, did dialysis center
staff keep information about you and
your health as private as possible from
other patients?

Never
Sometimes
Usually
Always

Yes
No

11. In the last 3 months, how often did the
dialysis center staff explain things in a
way that was easy for you to
understand?

17. In the last 3 months, did you feel
comfortable asking the dialysis center
staff everything you wanted about
dialysis care?

Never
Sometimes
Usually
Always

Yes
No
3

IPS_ICH_CAHPS_SVY_03.21

18. In the last 3 months, has anyone on
the dialysis center staff asked you
about how your kidney disease affects
other parts of your life?

24. In the last 3 months, how often was the
dialysis center staff able to manage
problems during your dialysis?
Never
Sometimes
Usually
Always

Yes
No
19. The dialysis center staff can connect
you to the dialysis machine through a
graft, fistula, or catheter. Do you know
how to take care of your graft, fistula,
or catheter?

25. In the last 3 months, how often did
dialysis center staff behave in a
professional manner?
Never
Sometimes
Usually
Always

Yes
No
20. In the last 3 months, which one did
they use most often to connect you to
the dialysis machine?

Please remember that for these questions,
dialysis center staff does not include
doctors. Dialysis center staff means nurses,
technicians, dietitians, and social workers
at this dialysis center.

Graft
Fistula
Catheter If Catheter, Go to
Question 22
I don’t know If Don’t Know, Go to
Question 22

26. In the last 3 months, did dialysis center
staff talk to you about what you should
eat and drink?

21. In the last 3 months, how often did
dialysis center staff insert your
needles with as little pain as possible?

Yes
No
27. In the last 3 months, how often did
dialysis center staff explain blood test
results in a way that was easy to
understand?

Never
Sometimes
Usually
Always
I insert my own needles

Never
Sometimes
Usually
Always

22. In the last 3 months, how often did
dialysis center staff check you as
closely as you wanted while you were
on the dialysis machine?

28. As a patient you have certain rights.
For example, you have the right to be
treated with respect and the right to
privacy. Did this dialysis center ever
give you any written information about
your rights as a patient?

Never
Sometimes
Usually
Always
23. In the last 3 months, did any problems
occur during your dialysis?
Yes
No

Yes
No

If No, Go to Question 25
4

IPS_ICH_CAHPS_SVY_03.21

29. Did dialysis center staff at this center
ever review your rights as a patient
with you?

34. In the last 3 months, how often was the
dialysis center as clean as it could be?
Never
Sometimes
Usually
Always

Yes
No
30. Has dialysis center staff ever told you
what to do if you experience a health
problem at home?

35. Using any number from 0 to 10, where
0 is the worst dialysis center possible
and 10 is the best dialysis center
possible, what number would you use
to rate this dialysis center?

Yes
No
31. Has any dialysis center staff ever told
you how to get off the machine if there
is an emergency at the center?

0 Worst dialysis center possible
1
2
3
4
5
6
7
8
9
10 Best dialysis center possible

Yes
No
32. Using any number from 0 to 10, where
0 is the worst dialysis center staff
possible and 10 is the best dialysis
center staff possible, what number
would you use to rate your dialysis
center staff?
0 Worst dialysis center staff possible
1
2
3
4
5
6
7
8
9
10 Best dialysis center staff possible

TREATMENT
The next few questions ask about your care
in the last 12 months. As you answer these
questions, think only about your experience
at <>, even if you
have not been receiving care there for the
entire 12 months.
36. You can treat kidney disease with
dialysis at a center, a kidney transplant,
or with dialysis at home. In the last 12
months, did your kidney doctors or
dialysis center staff talk to you as much
as you wanted about which treatment is
right for you?

THE DIALYSIS CENTER
33. In the last 3 months, when you arrived
on time, how often did you get put on
the dialysis machine within 15 minutes
of your appointment or shift time?

Yes
No

Never
Sometimes
Usually
Always
5

IPS_ICH_CAHPS_SVY_03.21

37. Are you eligible for a kidney
transplant?

43. In the last 12 months, how often were
you satisfied with the way they
handled these problems?

Yes If Yes, Go to Question 39
No
I don’t know If Don’t Know, Go to
Question 39

Never
Sometimes
Usually
Always

38. In the last 12 months, has a doctor or
dialysis center staff explained to you
why you are not eligible for a kidney
transplant?

44. Medicare and your State have special
agencies that check the quality of care
at this dialysis center. In the last 12
months, did you make a complaint to
any of these agencies?

Yes
No

Yes
No

39. Peritoneal dialysis is dialysis given
through the belly and is usually done
at home. In the last 12 months, did
either your kidney doctors or dialysis
center staff talk to you about
peritoneal dialysis?

ABOUT YOU
45. In general, how would you rate your
overall health?

Yes
No

Excellent
Very good
Good
Fair
Poor

40. In the last 12 months, were you as
involved as much as you wanted in
choosing the treatment for kidney
disease that is right for you?
Yes
No

46. In general, how would you rate your
overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor

41. In the last 12 months, were you ever
unhappy with the care you received at
the dialysis center or from your kidney
doctors?
Yes
No

If No, Go to Question 45

47. Are you being treated for high blood
pressure?

42. In the last 12 months, did you ever talk
to someone on the dialysis center staff
about this?
Yes
No

Yes
No
48. Are you being treated for diabetes or
high blood sugar?

If No, Go to Question 45

Yes
No
6

IPS_ICH_CAHPS_SVY_03.21

49. Are you being treated for heart disease
or heart problems?

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

Yes
No

No formal education
5th grade or less
6th, 7th, or 8th grade
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

50. Are you deaf or do you have serious
difficulty hearing?
Yes
No
51. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?

57. What language do you mainly speak at
home?

Yes
No

English
Spanish
Chinese
Samoan
Russian
Vietnamese
Portuguese
Some other language (please
identify):
_______________________

52. Because of a physical, mental, or
emotional condition, do you have
serious difficulty concentrating,
remembering, or making decisions?
Yes
No
53. Do you have serious difficulty walking
or climbing stairs?

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

Yes
No

No, not Spanish/Hispanic/ Latino
Yes, Puerto Rican
Yes, Mexican, Mexican American,
Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/ Latino

54. Do you have difficulty dressing or
bathing?
Yes
No
55. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone, such as
visiting a doctor’s office or shopping?
Yes
No

7

IPS_ICH_CAHPS_SVY_03.21

59. What is your race? (One or more
categories may be selected.)

61. Who helped you complete this survey?
A family member
A friend
A staff member at the dialysis center
Someone else (please print):
________________________

White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

62. How did that person help you? Check
all that apply.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way (please
print):
________________________

60. Did someone help you complete this
survey?

Thank you.
Please return the survey in the enclosed
envelope.

Yes
No Thank you. Please return the
completed survey in the postagepaid envelope.

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. Healthcare 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
http://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:
Department of Veterans Affairs
c/o Ipsos
P.O. Box 806046
Chicago, IL 60680
8

IPS_ICH_CAHPS_SVY_03.21