VA Form 10-1465-8 SHEP In-Center Hemodialysis (ICHemo) Long Form 10-1465-8

OMB Number 2900-0712
Est. Burden: 15 minutes
VA Form 10-1465-8

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
IN-CENTER HEMODIALYSIS CARE 2013
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 25 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 VISIT TO A VA FACILITY ***
Our records show that you recently visited the VA facility described below. You will be asked to refer to this
information later in the survey:

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.
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.

1. Where do you get your dialysis
treatments?
1

2

4. In the last 3 months, how often did
your kidney doctors explain things in a
way that was easy for you to
understand?

At home  Thank you. Please
return the completed survey in the
postage-paid envelope.
At the dialysis center

1
2
3

2. How long have you been getting
dialysis at this dialysis center?
1

2
3
4

4

Less than 3 months  Thank you.
Please return the completed survey
in the postage-paid envelope.
At least 3 months but less than 1 year
At least 1 year but less than 5 years
5 years or more

Never
Sometimes
Usually
Always

5. In the last 3 months, how often did
your kidney doctors show respect for
what you had to say?
1
2
3
4

Never
Sometimes
Usually
Always

YOUR KIDNEY DOCTORS
6. In the last 3 months, how often did
your kidney doctors spend enough
time with you?

For the questions that follow, your kidney
doctors means the doctor or doctors most
involved in your dialysis care now. This
could include kidney doctors that you see
inside and outside the center.

1
2
3

3. In the last 3 months, how often did
your kidney doctors listen carefully to
you?
1
2
3
4

4

Never
Sometimes
Usually
Always

7. In the last 3 months, how often did you
feel your kidney doctors really cared
about you as a person?

Never
Sometimes
Usually
Always

1
2
3
4

2

Never
Sometimes
Usually
Always

8. Using any number from 0 to 10 where
0 is the worst kidney doctors possible
and 10 is the best kidney doctors
possible, what number would you use
to rate the kidney doctors you have
now?
0
1
2
3
4
5
6
7
8
9
10

11. In the last 3 months, how often did the
dialysis center staff explain things in a
way that was easy for you to
understand?
1
2

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

3
4

12. In the last 3 months, how often did the
dialysis center staff show respect for
what you had to say?
1
2
3
4

2

1

Yes
No

2
3
4

THE DIALYSIS CENTER STAFF

1
2

10. In the last 3 months, how often did the
dialysis center staff listen carefully to
you?
2
3
4

Never
Sometimes
Usually
Always

14. In the last 3 months, how often did you
feel the dialysis center staff really
cared about you as a person?

For the next questions, dialysis center staff
does not include doctors. Dialysis center
staff means nurses, technicians, dietitians
and social workers at this dialysis center.

1

Never
Sometimes
Usually
Always

13. In the last 3 months, how often did the
dialysis center staff spend enough
time with you?

9. Do your kidney doctors seem informed
and up-to-date about the health care
you receive from other doctors?
1

Never
Sometimes
Usually
Always

3
4

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

15. In the last 3 months, how often did
dialysis center staff make you as
comfortable as possible during
dialysis?
1
2
3
4

2

Never
Sometimes
Usually
Always

16. In the last 3 months, did dialysis
center staff keep information about
you and your health as private as
possible from other patients?
1
2

21. In the last 3 months, how often did
dialysis center staff insert your
needles with as little pain as possible?
1

Yes
No

2
3
4

17. In the last 3 months, did you feel
comfortable asking the dialysis center
staff everything you wanted about
dialysis care?
1
2

5

22. In the last 3 months, how often did
dialysis center staff check you as
closely as you wanted while you were
on the dialysis machine?

Yes
No

1

18. In the last 3 months, has anyone on
the dialysis center staff asked you
about how your kidney disease affects
other parts of your life?
1
2

2
3
4

Yes
No

1

2

2

2
3

4

Yes
No  If No, Go to Question 25

24. In the last 3 months, how often was
the dialysis center staff able to
manage problems during your
dialysis?

Yes
No

1
2

20. In the last 3 months, which one did
they use most often to connect you to
the dialysis machine?
1

Never
Sometimes
Usually
Always

23. In the last 3 months, did any problems
occur during your dialysis?

19. The dialysis center staff can connect
you to the dialysis machine through a
graft, fistula, or catheter. Do you know
how to take care of your graft, fistula
or catheter?
1

Never
Sometimes
Usually
Always
I insert my own needles

3
4

Graft
Fistula
Catheter  If Catheter, Go to
Question 22
I don’t know  If Don’t Know, Go to
Question 22

Never
Sometimes
Usually
Always

25. In the last 3 months, how often did
dialysis center staff behave in a
professional manner?
1
2
3
4

Never
Sometimes
Usually
Always

Please remember that for these questions,
dialysis center staff does not include
doctors. Dialysis center staff means nurses,
technicians, dietitians and social workers at
this dialysis center.
3

26. In the last 3 months, did dialysis
center staff talk to you about what you
should eat and drink?
1
2

32. Using any number from 0 to 10 where
0 is the worst dialysis center staff
possible and 10 is the best dialysis
center staff possible, what number
would you use to rate your dialysis
center staff?

Yes
No

0

27. In the last 3 months, how often did
dialysis center staff explain blood test
results in a way that was easy to
understand?
1
2
3
4

1
2
3
4

Never
Sometimes
Usually
Always

5
6
7
8
9

28. As a patient you have certain rights.
For example, you have the right to be
treated with respect and the right to
privacy. Did this dialysis center ever
give you any written information about
your rights as a patient?
1
2

10

THE DIALYSIS CENTER
33. In the last 3 months, when you arrived
on time, how often did you get put on
the dialysis machine within 15 minutes
of your appointment or shift time?

Yes
No

29. Did dialysis center staff at this center
ever review your rights as a patient
with you?
1
2

1
2
3

Yes
No

4

2

1

Yes
No

2
3
4

31. Has any dialysis center staff ever told
you how to get off the machine if there
is an emergency at the center?
1
2

Never
Sometimes
Usually
Always

34. In the last 3 months, how often was
the dialysis center as clean as it could
be?

30. Has dialysis center staff ever told you
what to do if you experience a health
problem at home?
1

0 Worst dialysis center staff possible
1
2
3
4
5
6
7
8
9
10 Best dialysis center staff possible

Yes
No

4

Never
Sometimes
Usually
Always

35. Using any number from 0 to 10, where
0 is the worst dialysis center possible
and 10 is the best dialysis center
possible, what number would you use
to rate this dialysis center?
0
1
2
3
4
5
6
7
8
9
10

39. Peritoneal dialysis is dialysis given
through the belly and is usually done
at home. In the last 12 months, did
either your kidney doctors or dialysis
center staff talk to you about
peritoneal dialysis?

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

1
2

40. In the last 12 months, were you as
involved as much as you wanted in
choosing the treatment that is right for
you?
1
2

The next few questions ask about your care
in the last 12 months.

1
2

36. You can treat kidney disease with
dialysis, kidney transplant or with
dialysis at home. In the last 12 months,
did your kidney doctors or dialysis
center staff talk to you as much as you
wanted about which treatment is right
for you?
2

2
3

1
2

Yes
No

2

Yes
No  If No, Go to Question 45 on
page 7

43. In the last 12 months, how often were
you satisfied with the way they
handled these problems?
1

Yes  If Yes, Go to Question 39
No
Don’t know  If Don’t Know, Go to
Question 39

2
3
4

Never
Sometimes
Usually
Always

44. Medicare and your State have special
agencies that check the quality of care
at this dialysis center. In the last 12
months, did you make a complaint to
any of these agencies?

38. In the last 12 months, has a doctor or
dialysis center staff explained to you
why you are not eligible for a kidney
transplant?
1

Yes
No  If No, Go to Question 45 on
page 7

42. In the last 12 months, did you ever talk
to someone on the dialysis center staff
about this?

37. Are you eligible for a kidney
transplant?
1

Yes
No

41. In the last 12 months, were you ever
unhappy with the care you received at
the dialysis center or from your kidney
doctors?

TREATMENT

1

Yes
No

Yes
No

1
2

5

Yes
No

52. Because of a physical, mental, or
emotional condition, do you have
serious difficulty concentrating,
remembering, or making decisions?

ABOUT YOU
45. In general, how would you rate your
overall health?
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

1
2

53. Do you have serious difficulty walking
or climbing stairs?
1

46. In general, how would you rate your
overall mental or emotional health?
1
2
3
4
5

2

Excellent
Very good
Good
Fair
Poor

2

1
2

Yes
No

1

48. Are you being treated for diabetes or
high blood sugar?
2

2

Yes
No








Yes
No

2


English

Spanish

Chinese

Russian

Vietnamese

Some other language (please print):
_______________________________

Yes
No

51. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
1
2

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

57. What language do you mainly speak at
home?

50. Are you deaf or do you have serious
difficulty hearing?
1

Yes
No

56. What is the highest grade or level of
school that you have completed?

49. Are you being treated for heart disease
or heart problems?
1

Yes
No

55. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such as
visiting a doctor’s office or shopping?
2

1

Yes
No

54. Do you have difficulty dressing or
bathing?

47. Are you being treated for high blood
pressure?
1

Yes
No

Yes
No
6

58. Are you of Spanish, Hispanic, or
Latino origin or descent?

61. Who helped you complete this survey?
1

A family member
A friend
3
A staff member at the dialysis center
4
Someone else (please print):
____________________________



Yes, Hispanic or Latino
 No, Not Hispanic or Latino

2

59. What is your race? (One or more
categories may be selected.)






62. How did that person help you? Check
all that apply.

White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native

1

Read the questions to me
Wrote down the answers I gave
3
Answered the questions for me
4
Translated the questions into my
language
5
Helped in some other way (please
print):
____________________________
2

60. Did someone help you complete this
survey?
1
2

Yes
No  Thank you. Please return the
completed survey in the postagepaid envelope.

Thank you. Please return the survey in the enclosed envelope.
END OF QUESTIONS

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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