Form VA Form 10-0522 VA Form 10-0522 Project ARCH (Access Received Closer to Home) Patient Sa

PROJECT ARCH
(ACCESS RECEIVED CLOSER TO HOME)

PATIENT SATISFACTION SURVEY
Your answers to the following short questionnaire will help the Department of Veterans Affairs (VA)
understand your satisfaction with the care you received when you were referred for care outside of a VA
facility through Project ARCH (Access Received Closer to Home).
Your answers and feedback are important to help us ensure the quality of health care provided by Project
ARCH providers, and all information is strictly SULYDWHWRWKHH[WHQWRIWKHODZ. 3DUWLFLSDWLQJLQWKLVVXUYH\
will not affect your VA care.
Please read each question and check the box that best describes your experience using blue or black ink
pen. Please be sure to read all pages of this questionnaire.
According to our records, you recently had a health care visit with a Project ARCH provider, on [VISIT
DATE]. When answering the questions, think only about your visit with the Project ARCH provider and do
not include any visits with a VA provider or a non-Project ARCH provider in your answers.

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 12 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.

Estimated Burden: 12 minutes
OMB 2900-0770

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VA Form 10-0522
September 2011

DO NOT SHARE – FOR INTERNAL STAFF ONLY

SURVEY INSTRUCTIONS
•

Answer all 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.

•

You are sometimes asked to provide further explanation in this survey. When this happens you will see a blank line
under the option “Other”, like this:

Other (Please explain below)

Please explain further by writing on top of the blank line legibly.
•

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 questions to answer next, like this:

Yes

No  If No, please go to Q13
SURVEY

Project ARCH is a VA pilot program that provides health
care closer to your home by contracting with non-VA
providers.

Q3.

Why did you decide to participate in
Project ARCH (Check all that apply)?
 Project ARCH provider is located closer to
my home
 Reputation of the Project ARCH provider
 Word of mouth from other Veterans
 Recommendation by the VA provider
 Other (Please explain below)

A Project ARCH provider could be any health care
provider who is not employed by VA but is providing
health care services to you under the Project ARCH
program.
A VA provider could be any health care provider you
would see for health care who is a VA employee.
Q1.

Did you receive care from a Project ARCH
provider?
 Yes
 No

Q4.

What Project ARCH information did you
receive and was it useful?
Yes
No
N/A
a. Consent form
 
If yes, was it useful?
  
b. Project ARCH staff
 
contact information
If yes, was it useful?
  
c. Project ARCH website
 
address
If yes, was it useful?
  
d. Frequently Asked
 
Questions
If yes, was it useful?
  
e. Other (please explain
below)
 

If your answer to the above question Q1 was “No”,
STOP, you are finished with the survey. Thank you
for your time. Please submit the survey in the
postage-paid envelope provided.
BEFORE RECEIVING CARE
Q2.

How did you first find out about Project ARCH?
 VA provider
 Project ARCH nurse care coordinator
 Other VA staff
 Project ARCH website
 Project ARCH provider
 Veteran Service Organization
 Other Veterans
 Other (Please explain below)

If yes, was it useful?

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VA Form 10-0522
September 2011

DO NOT SHARE – FOR INTERNAL STAFF ONLY







ACCESS TO THE PROJECT ARCH PROVIDER
Q5.

Q6.

Q7.

Q8.

Q9.

Q10. Were you hospitalized with at least one
overnight stay at the Project ARCH provider
site?
 Yes
 No  If No, please go to Q13

How long did you wait between the time you
were referred to the Project ARCH provider by
VA and the day you actually saw the Project
ARCH provider?
 Same day
 1 to 7 days
 8 to 14 days
 15 to 30 days
 More than 30 days

Q11. Wait time is time spent in the waiting room.
Approximately how long did you wait to be
seen by the Project ARCH provider beyond
your scheduled appointment time?
 No wait
 1 to 10 minutes
 11 to 20 minutes
 21 to 30 minutes
 31 to 60 minutes
 More than 1 hour

How satisfied were you with how long it took
between the time you were first referred by a
VA provider to receive care from a Project
ARCH provider and the day you actually saw
the Project ARCH provider?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied

Q12. How satisfied were you about how long you
waited to be seen by the Project ARCH
provider after your scheduled appointment
time?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied

Approximately how long did it take you to
travel to the Project ARCH provider site?
 Less than 30 minutes
 30 minutes to less than 60 minutes
 60 minutes to less than 90 minutes
 90 minutes to less than 120 minutes
 120 minutes to less than 240 minutes
 More than 240 minutes

DURING THE VISIT / ADMISSION
Q13. Did the Project ARCH provider(s) seem to
know your medical history?
 Yes
 Somewhat
 No
 I don’t know

How satisfied were you with how long it took
you to travel to the Project ARCH provider
site?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied

Q14. Did the Project ARCH provider(s) explain
things in a way you could understand?
 Yes
 Somewhat
 No

If you had to travel to a VA facility to get the
same type of care you just received from the
Project ARCH provider, approximately how
long would it have taken you to travel to the
VA facility?
 Less than 30 minutes
 30 minutes to less than 60 minutes
 60 minutes to less than 90 minutes
 90 minutes to less than 120 minutes
 120 minutes to less than 240 minutes
 More than 240 minutes

Q15. How satisfied were you with the amount of
time the Project ARCH provider(s) spent with
you?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied

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VA Form 10-0522
September 2011

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Q16. During your most recent office visit or
admission, how would you rate how you were
treated by the Project ARCH provider(s)?
 Excellent
 Very good
 Good
 Fair
 Poor

Q22. Did you know who your Project ARCH nurse
care coordinator was?
 Yes
 No
Q23. What did your Project ARCH nurse care
coordinator help you with (Check all that
apply)?
 S/he provided the consent form
 S/he explained what Project ARCH is and
provided informational materials
 S/he helped me schedule an appointment
with the Project ARCH provider
 S/he helped me get follow-up care from a
VA facility
 Did not get any help from her/him
 Other (Please explain below)
 N/A

Q17. During your most recent office visit or
admission, how would you rate how you were
treated by the office or hospital staff?
 Excellent
 Very good
 Good
 Fair
 Poor
Q18. How satisfied were you with the cleanliness
and safety of the Project ARCH provider site?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied

Q24. Do you feel that the Project ARCH nurse care
coordinator helped to improve your experience
in receiving the care you need?
 Definitely yes
 Somewhat
 Definitely no
 N/A

Q19. Overall, how satisfied were you with the health
care you received from the Project ARCH
provider(s)?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied

Q25. If you had any difficulties at the time of service
or any concerns about the care you received
from the Project ARCH provider(s), did you
know whom to contact?
 Yes, and it was resolved
 Yes, but it was not resolved
 No, I did not know whom to contact
 I did not have any difficulty or concern

FOLLOW UP CARE AND CARE MANAGEMENT
Q20. Did you need follow-up care?
 Yes
 No  If No, please go to Q22

OVERALL SATISFACTION
Q26. Do you feel that you received the same level of
care from the Project ARCH provider
compared to care you received at a VA facility?
 Definitely yes
 Somewhat
 Definitely no

Q21. How satisfied have you been with the follow-up
care received after the visit?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied
 No follow-up care needed or have not
received the follow-up care yet

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VA Form 10-0522
September 2011

DO NOT SHARE – FOR INTERNAL STAFF ONLY

Q27. Overall, how satisfied were you with the
Project ARCH program?
 Completely satisfied
 Somewhat satisfied
 Neither satisfied nor dissatisfied
 Somewhat dissatisfied
 Completely dissatisfied

ABOUT YOURSELF
Q30. In general, how would you rate your overall
health?
 Excellent
 Very good
 Good
 Fair
 Poor

Q28. Overall, would you go back to the Project
ARCH provider to receive care?
 Definitely yes
 Somewhat
 Definitely no
 Not sure / don’t know

Q31. Please select one that applies to you.
 I use VA for all my care
 I use VA for most of my care
 I use VA for some of my care

Q29. Overall, would you recommend Project ARCH
to other Veterans?
 Definitely yes
 Somewhat
 Definitely no
 Not sure / don’t know

Q32. Is there anything else you would like to share
about your experience with the Project ARCH
program?

Your answers are important to help us ensure the quality of health care provided by Project
ARCH providers. Thank you for completing this questionnaire. Please place the completed
questionnaire in the postage-paid envelop provided to you. Simply place the envelope in any
mailbox and the survey will be returned to:
Department of Veterans Affairs
[address]

5

VA Form 10-0522
September 2011

DO NOT SHARE – FOR INTERNAL STAFF ONLY