VA Form 10-1465-1 SHEP Inpatient Long Form

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OMB Number 2900-0712
Est. Burden: 20 minutes
VA Form 10-1465-1

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
RECENTLY DISCHARGED
INPATIENT
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.
We want to remind you that all information is strictly anonymous. It will not be shared with your doctor
or affect your VA care.
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 20 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.

*** ABOUT YOUR RECENT HOSPITAL STAY ***
We realize that you may receive care at more than one VA location. However, it is important that
you answer the questions in this survey based on your VA hospital stay described below:

Version: 61 - 0109

SURVEY INSTRUCTIONS
Answer all the questions by checking the box to the left of your answer. Make sure that your answer is marked
inside the box.
Please use blue or black ink pen, or pencil.
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:
 Yes
 No 
If No, Go to Question 1
You may notice a number on the cover of this survey. This number is ONLY used to let us know if you returned
your survey.
Please note: Questions 1–22 in this survey are part of a national initiative to measure the quality of care in
hospitals.
Please answer the questions in this survey about your stay at the hospital named on the cover of this survey
booklet. Do not include any other hospital stay in your answers.
YOUR CARE FROM NURSES

YOUR CARE FROM DOCTORS

1.

During this hospital stay, how often did
nurses treat you with courtesy and respect?
 Never
 Sometimes
 Usually
 Always

5.

During this hospital stay, how often did
doctors treat you with courtesy and respect?
 Never
 Sometimes
 Usually
 Always

2.

During this hospital stay, how often did
nurses listen carefully to you?
 Never
 Sometimes
 Usually
 Always

6.

During this hospital stay, how often did
doctors listen carefully to you?
 Never
 Sometimes
 Usually
 Always

3.

During this hospital stay, how often did
nurses explain things in a way you could
understand?
 Never
 Sometimes
 Usually
 Always

7.

During this hospital stay, how often did
doctors explain things in a way you could
understand?
 Never
 Sometimes
 Usually
 Always

4.

During this hospital stay, after you pressed
the call button, how often did you get help as
soon as you wanted it?
 Never
 Sometimes
 Usually
 Always
 I never pressed the call button

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THE HOSPITAL ENVIRONMENT
8.

During this hospital stay, how often were
your room and bathroom kept clean?
 Never
 Sometimes
 Usually
 Always

9.

During this hospital stay, how often was the
area around your room quiet at night?
 Never
 Sometimes
 Usually
 Always

YOUR EXPERIENCES IN THIS HOSPITAL
10. During this hospital stay, did you need help
from nurses or other hospital staff in getting
to the bathroom or in using a bedpan?
 Yes
 No 
If No, Go to Question 12
11. How often did you get help in getting to the
bathroom or in using a bedpan as soon as
you wanted?
 Never
 Sometimes
 Usually
 Always
12. During this hospital stay, did you need
medicine for pain?
 Yes
 No 
If No, Go to Question 15
13. During this hospital stay, how often was
your pain well controlled?
 Never
 Sometimes
 Usually
 Always

14. During this hospital stay, how often did the
hospital staff do everything they could to
help you with your pain?
 Never
 Sometimes
 Usually
 Always
15. During this hospital stay, were you given any
medicine that you had not taken before?
 Yes
 No 
If No, Go to Question 18
16. Before giving you any new medicine, how
often did hospital staff tell you what the
medicine was for?
 Never
 Sometimes
 Usually
 Always
17. Before giving you any new medicine, how
often did hospital staff describe possible side
effects in a way you could understand?
 Never
 Sometimes
 Usually
 Always
WHEN YOU LEFT THE HOSPITAL
18. After you left the hospital, did you go
directly to your own home, to someone else’s
home, or to another health facility?
 Own home
 Someone else’s home
 Another health facility 
If Another
Health Facility, Go to Question 21
19. During this hospital stay, did doctors, nurses
or other hospital staff talk with you about
whether you would have the help you needed
when you left the hospital?
 Yes
 No

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20. During this hospital stay, did you get
information in writing about what symptoms
or health problems to look out for after you
left the hospital?
 Yes
 No
OVERALL RATING OF HOSPITAL
Please answer the following questions about your
stay at the hospital named on the cover. Do not
include any other hospital stays in your answer.
21. Using any number from 0 to 10, where 0 is
the worst hospital possible and 10 is the best
hospital possible, what number would you
use to rate this hospital during your stay?
 0 Worst hospital possible
 1
 2
 3
 4
 5
 6
 7
 8
 9
 10 Best hospital possible
FURTHER QUESTIONS ABOUT
YOUR EXPERIENCE
22. Would you recommend this hospital to your
friends and family?
 Definitely no
 Probably no
 Probably yes
 Definitely yes
23. During this hospital stay, how often was
personal information about you treated in a
confidential manner?
 Never
 Sometimes
 Usually
 Always

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24. During this hospital stay, how often did
nurses show respect for what you had to
say?
 Never
 Sometimes
 Usually
 Always
25. During this hospital stay, how often did you
feel nurses really cared about you as a
person?
 Never
 Sometimes
 Usually
 Always
26. During this hospital stay, how often did
doctors show respect for what you had to
say?
 Never
 Sometimes
 Usually
 Always
27. During this hospital stay, how often did you
feel doctors really cared about you as a
person?
 Never
 Sometimes
 Usually
 Always
28. During this hospital stay, were providers
willing to talk to your family or friends
about your health or treatment?
 Yes
 No
29. During this hospital stay, how often did you
have a hard time speaking with or
understanding your doctors or other health
providers because you spoke different
languages?
 Never
 Sometimes
 Usually
 Always

30. During this hospital stay, did providers at
this hospital give you complete and accurate
information about:

a) Tests?

Yes


No


Does Not
Apply


b) Choices for
your care?







c)







d) Plan for your
care?







e)

Medications?







f)

Follow-up care?













Treatment?

g) Side effects of
medications

31. If you could have free care outside the VA,
would you choose to be hospitalized here
again?
 Definitely would not
 Probably would not
 Probably would
 Definitely would
32. During this hospital stay, how often did
health care providers seem informed and
up-to-date about the care you got from other
providers at the hospital?
 Never
 Sometimes
 Usually
 Always
33. Were there times when you were confused
because different providers told you
different things?
 Yes, always
 Yes, sometimes
 No

35. During this hospital stay, when there was
more than one choice for your treatment or
health care, did providers ask which choice
you thought was best for you?
 Yes
 No
36. During this hospital stay, did providers talk
with you about the pros and cons of each
choice for your treatment or health care?
 Yes
 No
37. Did someone on the hospital staff tell you
what activities you could do after you got
home?
 Yes
 No
38. Did you know who to contact if you needed
medical advice or help right away, after you
went home?
 Yes
 No
ABOUT COMMUNICATING WITH VA
39. Did you have a complaint about how you
were treated (medically or personally)
during your last hospitalization?
 Yes
 No 
If No, Go to Question 45
40. If you reported this complaint to someone at
the VA location where you received your
care, to whom did you report this
complaint?
 Treatment team 
Go to Question 42
 Patient advocate 
Go to Question 42
 Other VA staff 
Go to Question 42
 Did not report the complaint to a VA
employee

34. Did you know who to ask when you had
questions about your health care?
 Yes, always
 Yes, sometimes
 No

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41. If you did not report this complaint, what
was the most important reason you did
not report it? (Please mark only one)
 I didn't know where to complain
 I was afraid of what would happen if I
did complain
 I thought complaining wouldn't do
any good
 I wasn't sure I had the right to complain
 Other
42. 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
43. If you spoke with someone at the VA
location about a complaint, how satisfied
were you with the way your complaint
was handled?
 Very satisfied
 Satisfied
 Dissatisfied
 Very dissatisfied
 Not applicable
44. How long did it take for the VA hospital
to resolve your complaint?
 Same day
 2-7 days
 8-14 days
 15-21 days
 More than 21 days
 Complaint is not resolved
 Not applicable

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SPIRITUAL NEEDS
Please tell us whether each of the following
statements describes you and how your spiritual
needs were met during this hospital stay.
45. My religious/spiritual needs are
an important part of my overall
care.
 Yes
 No
 Not applicable
46. I was asked if I had any
religious/spiritual needs during my stay.
 Yes
 No
 Not applicable
47. My religious/spiritual needs were
appropriately assessed and
addressed.
 Yes
 No
 Not applicable
48. Literature in keeping with my faith
was offered to me.
 Yes
 No
 Not applicable

YOUR OVERALL EXPERIENCE WITH THE
DEPARTMENT OF VETERANS AFFAIRS
Now think about your experiences with all the
services provided by the Department of Veterans
Affairs (which include healthcare, benefits
programs, or memorial services). Please tell us
how you feel about the following statements:
49. I got the service I needed.







Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

50. It was easy to get the service I needed.







Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

51. I felt like a valued customer.







Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

52. I trust VA to fulfill our country’s commitment to
veterans.







Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

ABOUT YOUR HEALTH
53. In general, how would you rate your
overall health?
 Excellent
 Very good
 Good
 Fair
 Poor
54. The following two questions are about
activities you might do during a
typical day. Does your health now
limit you in these activities? If so, how
much?
a. Moderate activities, such as moving a
table, pushing a vacuum cleaner,
bowling, or playing golf?
 Yes, limited a lot
 Yes, limited a little
 No, not limited at all
b. Climbing several flights of stairs?
 Yes, limited a lot
 Yes, limited a little
 No, not limited at all
55. During the past 4 weeks, have you
had any of the following problems
with your work or other regular daily
activities as a result of your physical
health?
a. Accomplished less than you would like?
 No, none of the time
 Yes, a little of the time
 Yes, some of the time
 Yes, most of the time
 Yes, all of the time
b. Were limited in the kind of work or
other activities?
 No, none of the time
 Yes, a little of the time
 Yes, some of the time
 Yes, most of the time
 Yes, all of the time

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56. During the past 4 weeks, have you had any
of the following problems with your work
or other regular daily activities as a result
of any emotional problems (such as feeling
depressed or anxious)?
a. Accomplished less than you would like
 No, none of the time
 Yes, a little of the time
 Yes, some of the time
 Yes, most of the time
 Yes, all of the time
b. Didn't do work or other activities
as carefully as usual
 No, none of the time
 Yes, a little of the time
 Yes, some of the time
 Yes, most of the time
 Yes, all of the time

8

57. How much of the time during the past 4
weeks has your physical health or emotional
problems interfered with your social
activities (like visiting with friends, relatives,
etc.)?
 All of the time
 Most of the time
 Some of the time
 A little of the time
 None of the time
58. Compared to one year ago, how would you
rate your physical health in general now?
 Much better
 Somewhat better
 About the same
 Somewhat worse
 Much worse
59. During the past 4 weeks, how much did pain
interfere with your normal work (including
both work outside the home and
housework)?
 Not at all
 A little bit
 Moderately
 Quite a bit
 Extremely

60. How much of the time during the past 4 weeks:
All of the
time
a.

Have you felt calm and
peaceful?

b. Did you have a lot of
energy?
c.

Have you felt downhearted
and blue?

Most of
the time

A good
bit of the
time

Some of
the time

A little of
the time

None of
the time





































61. Compared to one year ago, how would you
rate your emotional problems (such as
feeling anxious, depressed or irritable) now?
 Much better
 Somewhat better
 About the same
 Somewhat worse
 Much worse
62. How much of the time during the past week,
did you feel depressed?
 Rarely or none of the time (less than 1 day)
 Some or a little of the time (1-2 days)
 Occasionally or a moderate amount of the
time (3-4 days)
 Most or all of the time (5-7 days)
63. In the past year, have you had 2 weeks or
more when you felt sad, blue or depressed
or when you lost interest or pleasure in
things that you usually cared about or
enjoyed?
 Yes
 No

64. Have you had 2 years or more in your life
when you felt depressed or sad most days, even
if you felt okay sometimes?
 Yes
 No
ABOUT THE HOSPITAL
65. How would you rate the hospital building
overall (e.g., attractiveness of facility
appearance, quality of building maintenance
and upkeep)?
 Poor
 Fair
 Good
 Very good
 Excellent
66. In terms of your satisfaction, how would you
rate the convenience of the location of the
facility?
 Poor
 Fair
 Good
 Very good
 Excellent

67. How would you rate the following aspects of your room:
Very
Good


Does Not
Excellent
Apply



Poor


Fair


Good


b. Privacy of your room













c.

























a.

Cleanliness of your room
Noise level

d. Sense of safety and security

9

68. How would you rate the following aspects of the equipment and facilities:
Poor
a.

Ease of finding your way
around the hospital

b. Availability of parking

Very
Good

Excellent

Does Not
Apply























69. Have you ever smoked cigarettes?
 Yes, still smoking every day 
Go to
Question 71
 Yes, still smoking some days 
Go to
Question 71
 Yes, but no longer smoke at all 
Go to
Question 70
 No, never smoked 
Go to Question 77
70. If you used to smoke but no longer do so,
about how long has it been since you last
smoked cigarettes at all?
 Less than 1 month
 1-5 months
 6-12 months
 1-5 years 
If 1-5 Years, Go to
Question 77
 More than 5 years 
If More Than 5
Years, Go to Question 77
71. In the past 12 months, have you stopped
smoking for 1 day or longer because you
were trying to quit smoking?
 Yes
 No
72. During the past 12 months, has a VA doctor
or other VA health care provider asked if
you were interested in stopping smoking?
 Yes
 No

10

Good



ABOUT TOBACCO

73. During the past 12 months, were you
treated for smoking within the VA?
 Yes
 No 
If No, Go to Question 77

Fair

74. If you were treated for smoking, where did you
receive the majority of your treatment?
 VA primary care provider
 VA mental health care provider
 VA smoking cessation clinic or program
 Other VA provider or program
75. During the past 12 months, what services were
recommended or offered to you by VA
providers or VA treatment programs to help
you stop smoking?
Mark all that apply.
 Self-help materials
 Nicotine replacement medication (patch,
gum, nasal spray or inhaler)
 Zyban, an antismoking medication (also
called Bupropion or Wellbutrin)
 Individual counseling
 Group counseling
 Telephone counseling
76. During the past 12 months, which of the
following services did you actually use to help
you stop smoking?
Mark all that apply.
 Self-help materials
 Nicotine replacement medication (patch,
gum, nasal spray or inhaler)
 Zyban, an antismoking medication (also
called Bupropion or Wellbutrin)
 Individual counseling
 Group counseling
 Telephone counseling

ABOUT ALCOHOL
77. How often did you have a drink containing
alcohol in the past 12 months? Consider a
"drink" to be a can or bottle of beer, a glass
of wine, a wine cooler, or one cocktail or a
shot of hard liquor (like scotch, gin or
vodka).
Please mark only one.
 Never 
If Never, Go to Question 81
 Monthly or less
 2-4 times a month
 2-3 times a week
 4-5 times a week
 6 or more times a week
78. How many drinks containing alcohol did
you have on a typical day when you were
drinking in the past 12 months?
 0 drinks (Did not drink in the past 12
months) 
If 0, Go to Question 81
 1-2 drinks
 3-4 drinks
 5-6 drinks
 7-9 drinks
 10 or more drinks
79. How often did you have 6 or more drinks on
one occasion in the past 12 months?
 Never
 Less than monthly
 Monthly
 Weekly
 Daily or almost daily

80. In the past 12 months has a VA doctor or other
VA health care provider advised you about
your drinking (to drink less or not to drink
alcohol)?
 Yes
 No
ABOUT YOU
There are only a few remaining items left.
81. What is the highest grade or level of school
that you have completed?
 8th grade or less
 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
82. Are you of Spanish, Hispanic or Latino origin
or descent?
 No, not Spanish/Hispanic/Latino
 Yes, Puerto Rican
 Yes, Mexican or
Mexican American
 Yes, Cuban
 Yes, other Spanish/Hispanic/Latino
83. What is your race? Mark all that apply.
 White
 Black or African American
 Asian
 Native Hawaiian or other Pacific Islander
 American Indian or Alaska Native
84. What language do you mainly speak at home?
 English
 Spanish
 Some other language (please print):

9

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. Health Care 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 Synovate
P.O. Box 806046
Chicago, IL 60680

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