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Department of Veterans Affairs
SURVEY OF PATIENT SATISFACTION
AT SURGICAL SERVICE
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.
*** YOUR RECENT SURGERY PROCESS TO A VA FACILITY ***
VA Form
JAN 2014
10-211015
1
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.
_______________________________________________________________________________
For the purpose of quality which section of the department of surgery offered the service?
_______________________________________________________________________________
Anesthesia
Urology
General surgery
Ophthalmology
Gynecology
Orthopedics
Dental
Neurosurgery
Plastic surgery
Cardiology
Please specify month of visit: __________________
________________________________________________________________________________
At clinics you’re your surgeon
During your office visits before your surgery, did this surgeon treat you with courtesy and
respect?
Never
Sometimes
Usually
Always
During your office visits before your surgery, did the surgeon tell you there was more than one way to
treat your condition?
Never
Sometimes
Usually
Always
During your office visits before your surgery, did the surgeon talk with you about risks and benefits of
your treatment choices?
Never
Sometimes
Usually
Always
VA Form
JAN 2014
10-211015
2
_________________________________________________________________________________
Before Your Surgery at Ambulatory Surgery Clinic
_______________________________________________________________________________
During the orientation at Ambulatory Surgery Clinic the nurses were courteous and respectful, listened
carefully, and explained things clearly.
Never
Sometimes
Usually
Always
The nursing staff at ambulatory surgery gives you written orientation about surgery process?
Never
Sometimes
Usually
Always
During these visits, were clerks at ambulatory surgery clinic as helpful as you thought they should be
with check in process?
Never
Sometimes
Usually
Always
Did this anesthesiologist encourage you to ask questions and answer your questions clearly?
Never
Sometimes
Usually
Always
________________________________________________________________________________
At waiting area prior your surgery
________________________________________________________________________________
After being changed clothes and passed into the waiting area of the operating room do you mean that
the service offered by staff was appropriate?
Never
Sometimes
Usually
Always
VA Form
JAN 2014
10-211015
3
After being changed clothes and passed into the waiting area of the operating room you understand
that there was excessive noise.
Never
Sometimes
Usually
Always
________________________________________________________________________________
After your surgery
________________________________________________________________________________
You think the nursing service in the recovery phase will handle the pain problem immediately you
request for them.
Never
Sometimes
Usually
Always
Did you get information in writing about further appointments and what symptoms or health problems
to look out after you left the hospital?
Never
Sometimes
Usually
Always
During this surgical experience were surgeons willing to response to your family or friends regarding
your surgery process?
Never
Sometimes
Usually
Always
_________________________________________________________________________________
Time Taken at Pharmacy
_________________________________________________________________________________
How long did you wait for your prescriptions to be filled at the VA pharmacy?
10-15MINUTES
16-30MINUTES
30-60MINUTES
1HOUR
2HOURS OR MORE
VA Form
JAN 2014
10-211015
4
________________________________________________________________________________
Overall satisfaction
________________________________________________________________________________
Are you satisfied with the surgical services after your experience at this Veterans Hospital and would
use again in other surgical event?
Never
Sometimes
Usually
Always
Thank you for completing this questionnaire. Your answers are important to help us improve
VA care. 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.
If you have a specific question or need help with your VA care, you may contact the VA
or visit at:
VA Caribbean Healthcare System
10 Casia Street
San Juan, PR 00921
Phone: (787) 641-7582
Fax: (787) 641-4557
Toll Free: 1-800-449-8729
Or contact:
Patient Representative
Mr. Claudio Santiago
Ms. Saribel Padilla
Phone: (787) 641-7582 Ext. 11725/11486
Administration Building
1st floor, Room D 1110-A
Thank You.
Please return the completed survey in the postage-paid envelope
VA Form
JAN 2014
10-211015
5
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| File Type | application/pdf |
| Author | EIE Desktop Technologies |
| File Modified | 2014-01-22 |
| File Created | 2014-01-22 |