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OMB Number 2900-new
Est. Burden: 30 minutes
VA Form 10-21083b(NR)

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
RECENTLY DISCHARGED INPATIENT 2004

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 questionnaire. Your answers help
ensure that all veterans receive the highest quality care they have earned and so richly deserve.
We want to remind you that all information is strictly anonymous. It will not be shared with your doctor or
affect your VA care.
Please read each question and fill in the circle that best describes your experience. Use blue or black ink
pen, or pencil. Please be sure to read all pages of this booklet.

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
30 minutes. This includes the time it will take to read instructions, gather the necessary
facts and fill out the form. Surveys of healthcare experiences are used to gauge customer
perceptions of VA services as well as gather information on patient's functional status
and health behaviors. 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 nonidentifying 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.

Please answer all survey questions about your hospitalization at:

Alpha Hospital, ending on March 3, 2003.

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PIease answer the questions in this survey about this stay at
AIpha HospitaI on March 3, 2003. Do not incIude any other
hospitaI stay in your answers.

5. Using any number from 0 to 10 where 0 is the worst possibIe
care and 10 is the best possibIe care, what number wouId you
give the care you got from aII the nurses who treated you?
E
E
E
E
E
E
E
E
E
E
E

YOUR CARE FROM NURSES

1. During this hospitaI stay, how often did nurses treat you with
courtesy and respect?
E
E
E
E

Never
Sometimes
Usually
Always

YOUR CARE FROM DOCTORS

2. During this hospitaI stay, how often did nurses Iisten carefuIIy to
you?
E
E
E
E

Never
Sometimes
Usually
Always

4. During this hospitaI stay, after you pressed the caII button, how
often did you get heIp as soon as you wanted it?

E
E
E
E
E

Never
Sometimes
Usually
Always
I never pressed the call button

*001AMD25*

6. During this hospitaI stay, how often did doctors treat you with
courtesy and respect?
E
E
E
E

3. During this hospitaI stay, how often did nurses expIain things in
a way you couId understand?
E
E
E
E

0 Worst possible nursing care
1
2
3
4
5
6
7
8
9
10 Best possible nursing care

Never
Sometimes
Usually
Always

7. During this hospitaI stay, how often did doctors Iisten carefuIIy
to you?
E
E
E
E

Never
Sometimes
Usually
Always

8. During this hospitaI stay, how often did doctors expIain things in
a way you couId understand?
E
E
E
E

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Never
Sometimes
Usually
Always

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9. Using any number from 0 to 10 where 0 is the worst possibIe
care and 10 is the best possibIe care, what number wouId you
give the care you got from aII the doctors who treated you?
E
E
E
E
E
E
E
E
E
E
E

0 Worst possible doctor care
1
2
3
4
5
6
7
8
9
10 Best possible doctor care

THE HOSPITAL ENVIRONMENT

10. During this hospitaI stay, how often were your room and
bathroom kept cIean?
E
E
E
E

Never
Sometimes
Usually
Always

11. During this hospitaI stay, how often was the area around your
room quiet at night?
E
E
E
E

Never
Sometimes
Usually
Always

YOUR EXPERIENCES IN THIS HOSPITAL

12. During this hospitaI stay, did you need heIp from doctors, nurses
or other hospitaI staff in getting to the bathroom or in using a
bedpan?
E
E

13. How often did you get heIp in getting to the bathroom or in using
a bedpan as soon as you wanted?
E
E
E
E

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Never
Sometimes
Usually
Always

14. During this hospitaI stay, did you need medicine for pain?
E
E

Yes
No > Go to Question 17

15. During this hospitaI stay, how often was your pain weII
controIIed?
E
E
E
E

Never
Sometimes
Usually
Always

16. During this hospitaI stay, how often did the hospitaI staff do
everything they couId to heIp you with your pain?
E
E
E
E

Yes
No > Go to Question 14

*001AMD36*

Never
Sometimes
Usually
Always

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17. During your hospitaI stay, did doctors, nurses, or other hospitaI
staff ever ask if you were aIIergic to any medicine?
E
E

OVERALL RATING OF HOSPITAL
PIease answer the foIIowing questions about the stay at AIpha
HospitaI on March 3, 2003. Do not incIude any other hospitaI
stays in your answer.

Yes
No

18. During this hospitaI stay, were you given any medicine that you
had not taken before?
E
E

23. Using any number from 0 to 10, where 0 is the worst hospitaI
possibIe and 10 is the best hospitaI possibIe, what number wouId
you use to rate this hospitaI?

Yes
No > Go to Question 20

E
E
E
E
E
E
E
E
E
E
E

19. Before giving you the medicine, did hospitaI staff describe
possibIe side effects in a way you couId understand?
E
E

Yes
No

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

WHEN YOU LEFT THE HOSPITAL
24. WouId you recommend this hospitaI to your friends and famiIy?
20. After you Ieft the hospitaI, did you go directIy to your own home,
to someone eIse's home, or to another heaIth faciIity?
E
E
E

Own home
Someone else's home
Another health facility > Go to Question 23

E
E
E
E

Definitely no
Probably no
Probably yes
Definitely yes

MORE QUESTIONS ABOUT YOUR STAY AT THE HOSPITAL
21. During your hospitaI stay, did hospitaI staff taIk with you about
whether you wouId have the heIp you needed when you Ieft the
hospitaI?
E
E

By answering the next set of questions, you wiII give us more
detaiIed information about how we can improve the care and
treatment we provide. Again, pIease think onIy of your visit to
AIpha HospitaI on March 3, 2003.

Yes
No

22. During your hospitaI stay, did you get information in writing
about what symptoms or heaIth probIems to Iook out for after you
Ieft the hospitaI?

E
E

Yes
No

25. Was your hospitaI stay an emergency or pIanned in advance?
E
E

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Emergency
Planned in advance > Go to Question 28

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26. How organized was the care you received in the emergency
room?

31. If you had any anxieties or fears about your condition or
treatment, did a doctor discuss them with you?

27. WhiIe you were in the emergency room, did you get enough
information about your medicaI condition and treatment?

32. Did you have confidence and trust in the doctors treating you?

E
E
E
E

E
E
E
E
E

Not at all organized
Somewhat organized
Very organized
Didn't use emergency room

Yes, definitely
Yes, somewhat
No
Didn't want information
Didn't use emergency room

28. How organized was the admission process?
E
E
E

Not at all organized
Somewhat organized
Very organized

Yes
No
Didn't have to wait

Yes, completely
Yes, somewhat
No
Didn't have anxieties or fears

Yes, always

Yes, sometimes

33. Did doctors taIk in front of you as if you weren't there?
E

Yes, often

Yes, sometimes

34. If you had any anxieties or fears about your condition or
treatment, did a nurse discuss them with you?
Yes, completely
Yes, somewhat
No
Didn't have anxieties or fears

35. Did you have confidence and trust in the nurses treating you?
E

Yes, always

Yes, sometimes

HOSPITAL STAFF

36. Did nurses check your identification band before giving you any
medications, treatments, or tests?

30. Was there one particuIar doctor in charge of your care in the
hospitaI?

37. During your stay, did nurses inform you about what medicines
you were being given and why?

E
E
E
E

29. If you had to wait to go to your room, did someone from the
hospitaI expIain the reason for the deIay?
E
E
E

E
E
E
E

Yes

Not sure

*001AMD58*

E
E
E
E

*001AMD58*

Yes, always

Yes, sometimes

Yes, completely
Yes, somewhat
No
Didn't receive medicine

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38. Sometimes in the hospitaI, one doctor or nurse wiII say one thing
and another wiII say something quite different. Did this happen
to you?
E

Yes, always

Yes, sometimes

39. Did you have enough say about your treatment?
E

Yes, definitely

Yes, somewhat

Yes, definitely
Yes, somewhat
No
No family or friends were involved
Family didn't want or need to talk

41. How much information about your condition or treatment was
given to your famiIy or someone cIose to you?
E
E
E
E
E

Not enough
Right amount
Too much
No family or friends involved
Family didn't want or need information

42. Was it easy for you to find someone on the hospitaI staff to taIk
to about your concerns?
E
E
E
E

Yes, definitely
Yes, somewhat
No
Didn't want to talk/no concerns

43. Were your scheduIed tests and procedures performed on time?

E
E
E
E

E
E
E
E
E

40. Did your famiIy or someone eIse cIose to you have enough
opportunity to taIk to your doctor?
E
E
E
E
E

44. Did famiIy members or someone cIose to you ever have to do
something or say something to staff to be sure that your medicaI
needs were met?
Yes, always
Yes, sometimes
No
Don't know
Didn't have family members or others close to me
present

SURGERY

45. Did the surgeon expIain the risks and benefits of the surgery in a
way you couId understand?
E
E
E
E
E

Yes, completely
Yes, somewhat
No
Explained to spouse or someone else
I didn't want anything explained

46. Did the surgeon or any of your other doctors answer your
questions about the surgery in a way you couId understand?
E
E
E
E

Yes, completely
Yes, somewhat
No
I didn't have any questions

47. Did a doctor or nurse teII you accurateIy how you wouId feeI after
surgery?
E
E
E

Yes, completely
Yes, somewhat
No

Yes, always
Yes, sometimes
No
No tests/procedures

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48. Were the resuIts of the surgery expIained in a way you couId
understand?
E
E
E
E

ABOUT YOU

Yes, completely
Yes, somewhat
No
Explained to spouse or someone else

There are onIy a few remaining items Ieft.

GOING HOME

53. In generaI, how wouId you rate your overaII heaIth?
E
E
E
E
E

49. Did someone on the hospitaI staff expIain the purpose of the
medicines you were to take at home in a way you couId
understand?
E
E
E
E
E

Yes, completely
Yes, somewhat
No
Didn't need explanation
No medicines at home

54. In generaI, how wouId you rate your overaII mentaI or emotionaI
heaIth?
E
E
E
E
E

50. Did they teII you what danger signaIs about your iIIness or
operation to watch for after you went home?
E
E
E

Yes, completely
Yes, somewhat
No

Excellent
Very Good
Good
Fair
Poor

55. What is the highest grade or IeveI of schooI that you have
compIeted?
E
E
E
E
E
E

51. Did they teII you when you couId resume your usuaI activities,
such as when to go back to work or drive a car?
E
E
E

Excellent
Very Good
Good
Fair
Poor

Yes, completely
Yes, somewhat
No

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

56. Are you of Hispanic or Latino origin or descent?
52. Did the doctors and nurses give your famiIy or someone cIose to
you aII the information they needed to heIp you recover?

E
E
E
E
E

E
E

Yes, Hispanic or Latino
No, not Hispanic or Latino

Yes, definitely
Yes, somewhat
No
No family or friends involved
Family didn't want or need information

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57. What is your race? PIease choose one or more.
E
E
E
E
E
E

White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Indian or Alaskan Native
Other (please print): _____________________

58. What Ianguage do you mainIy speak at home?
E
E
E

English
Spanish
Some other language (please
print):_________________________

If you have a specific question or need heIp 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): 1-800-8294833
2. Information on a brad range of veterans' benefits is available on
our home
page at 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.

59. Did someone heIp you compIete this survey?
E
E

Yes > Go to Question 60
No > Go to Question 61

60. How did that person heIp you? Check aII that appIy.
E
E
E
E
E

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

61. If you couId change one thing about the hospitaI, what wouId it
be? (please print your answer on the lines provided below.)

Your answers are important to heIp us improve VA care. Thank
you for compIeting this questionnaire. PIease pIace the
compIeted questionnaire in the enveIope we sent you. No stamp
is required. SimpIy pIace the enveIope in any maiIbox and
return the survey to:

OQP/Performance AnaIysis Center for ExceIIence
C/O NationaI Research Corporation
P.O. Box 82660
LincoIn, NE 68501-2660

I 123ABC March 0000000000 Version 1 E-S #BWNHDJZ

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File Type	application/pdf
File Title	Va 5
File Modified	2008-01-25
File Created	2004-09-29