Admission Process Customer Satisfaction Survey - Roseburg VAMC

Admission Process Customer Service Satisfaction Survey – Roseburg VAMC

OMB No. 2900-0770
Estimated Burden: 5 minutes

Expiration Date: 08/31/2017

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 5 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this in-person survey will lead to improvements in the quality of service delivery by helping to achieve improved admission processes and services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Scripting for the Admission Process Customer Satisfaction Survey – Roseburg VAMC

General Interviewing Conventions and Instructions

• All text that appears in lowercase letters should be read.

• Text in UPPERCASE letters should not be read out loud.

• All questions and all answer categories should be read as they are worded.

• Text that is underlined should be emphasized.

• Characters in <> should not be read.

• [Square brackets] are used to indicate information filled in by surveyor.

INTRO 1 Hello [Patient Name], my name is [Surveyor Name and Title]. If you are feeling up to it I would like to speak with you about your admission to our facility.

<1> YES [GO TO INTRO 2]

<2> NO [GO TO INTRO 4]

INTRO 2 The Roseburg VA Medical Center is working to improve our admission process from the Emergency Department to the Inpatient Unit. The following four questions were developed to evaluate our process and your experience from the time the decision was made to admit you, until you arrived on the unit. I will also be asking four additional questions about your overall experience during this episode of care.

Participation in the survey is completely voluntary and will not affect your health care or your benefits. It should take about 5 minute to answer.

Would you like to participate in the survey?

<YES> [GO TO QUESTION 1]

<NO> [GO TO INTRO 4]

QUESTION 1: Using a number from 1 to 5, where 1 is the worst and 5 is the best, what number would you use to rate the communication about your pending admission from staff prior to arriving on the unit? 

1    2    3   4   5

QUESTION 2: Did you feel involved in the admission process? 

Yes

No

QUESTION 3: Are you satisfied with the amount of time it took to get you to the unit?

Yes

No

QUESTION 4: Do you feel that your needs were met prior to arriving on the unit (e.g. pain, hunger)?  

Yes

No

INTRO 3 The next set of questions, are about your overall experience.

QUESTION 5: I got the service I needed.

Strongly disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly agree

QUESTION 6: It was easy to get the service I needed.

Strongly disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly agree

QUESTION 7: I felt like a valued customer.

Strongly disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly agree

QUESTION 8: I trust VA to fulfill our country’s commitment to Veterans.

Strongly disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly agree

INTRO 4 Thank you so much for speaking with me today. I hope that your stay with us is a positive experience. If at any time you feel your needs aren’t being met please let your nursing staff or social worker know, so that they can address your needs.

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