Form 10-21083a(NR) HCAHPS Survey

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OMB Number 2900-New
Est. Burden: 15 minutes
VA Form 10-21083a(NR)

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
RECENTLY DISCHARGED INPATIENT 2007

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 confidential. 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 15 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 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.

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Please answer all survey questions about your hospitalization at:
Alpha VAMC ending on March 3, 2007.

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PIease answer the questions in this survey about this stay at
AIpha VAMC on March 3, 2007. Do not incIude any other
hospitaI stay in your answers.

YOUR CARE FROM DOCTORS
6. During this hospitaI stay, how often did doctors treat you with
courtesy and respect?
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

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

Never
Sometimes
Usually
Always

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

Never
Sometimes
Usually
Always

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?

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

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

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?

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E
E
E
E
E
E
E
E
E
E
E

Never
Sometimes
Usually
Always

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

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E
E
E
E

E
E
E
E

E
E
E
E
E
E
E
E
E
E
E

Never
Sometimes
Usually
Always
Never
Sometimes
Usually
Always

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

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Never
Sometimes
Usually
Always

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

Yes
No > Go to Question 14

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

Never
Sometimes
Usually
Always

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

Yes
No > Go to Question 17
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

Never
Sometimes
Usually
Always
Yes
No

Yes
No > Go to Question 20

Definitely no
Probably no
Probably yes
Definitely yes

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

Yes
No

Excellent
Very Good
Good
Fair
Poor

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

20. After you Ieft the hospitaI, did you go directIy to your own home,
to someone eIse's home, or to another heaIth faciIity?
Own home
Someone else's home
Another health facility > Go to Question 23

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

There are onIy a few remaining items Ieft.

WHEN YOU LEFT THE HOSPITAL

E
E
E

PIease answer the foIIowing questions about the stay at AIpha
HospitaI on March 3, 2005. Do not incIude any other hospitaI
stays in your answer.
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 during your stay?

ABOUT YOU

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

OVERALL RATING OF HOSPITAL

E
E
E
E

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

Yes
No

24. WouId you recommend this hospitaI to your friends and famiIy?

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

E
E

E
E
E
E
E
E
E
E
E
E
E

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

22. During this 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
E
E
E

Excellent
Very Good
Good
Fair
Poor

21. During this hospitaI stay, did doctors, nurses, or other hospitaI
staff taIk with you about whether you wouId have the heIp you
needed when you Ieft the hospitaI?

B

E
E

Yes
No

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

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

28. Are you of Hispanic or Latino origin or descent?
E
E

Yes, Hispanic or Latino
No, not Hispanic or Latino

29. 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): _____________________

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): 1-800-829-4833
2. Information on a broad 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.

30. What Ianguage do you mainIy speak at home?

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:

31. Did someone heIp you compIete this survey?

Office of QuaIity and Performance Data Center
C/O NationaI Research Corporation
P.O. Box 82660
LincoIn, NE 68501-2660

32. How did that person heIp you? Check aII that appIy.

HCAHPS® items and The NRC+Picker Group, All Rights Reserved
by respective party.

E
E
E

E
E
E
E
E
E
E

English
Spanish
Some other language (please
print):_________________________
Yes > Go to Question 32
No > Go to Question 33

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

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

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

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