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 15 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
4. In the last 3 months, how often did your
treatments?
kidney doctors explain things in a way that
was easy for you to understand?
1

2
2

1

Never
Sometimes
3
Usually
4
Always
5. In the last 3 months, how often did your
kidney doctors show respect for what you
had to say?

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

2

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

2
3
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

1
2
3
4

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

YOUR KIDNEY DOCTORS
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

Never
Sometimes
3
Usually
4
Always
7. In the last 3 months, how often did you feel
your kidney doctors really cared about you
as a person?
2

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

Never
Sometimes
Usually
Always

1

Never
Sometimes
Usually
Always

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?

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
3

0
1
2
3
4
5
6
7
8
9
10

0 Worst kidney doctors possible
1

4

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

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

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

1
2

Yes
No

3
4

Never
Sometimes
Usually
Always

THE DIALYSIS CENTER STAFF
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
2
3

10. In the last 3 months, how often did the
dialysis center staff listen carefully to you?
1
2
3
4

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

3

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

Yes
No

2

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

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

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

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?
0
1
2

1

Yes
2
No
27. In the last 3 months, how often did dialysis
center staff explain blood test results in a
way that was easy to understand?

3
4
5
6
7
8

1

Never
2
Sometimes
3
Usually
4
Always
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?

9
10

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

2

2
3
4

Yes
No

1

1

2

2

3

Yes
No
31. Has any dialysis center staff ever told you
how to get off the machine if there is an
emergency at the center?
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

2
3
4
5
6
7
8
9
10 Best dialysis center staff possible
THE DIALYSIS CENTER

1

1

0 Worst dialysis center staff possible
1

4

Yes
No

5

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

1

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

2

1
2

Yes
2
No
37. Are you eligible for a kidney transplant?

1

Never
Sometimes
3
Usually
4
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?

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

2

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
2

Yes
No 
If No, Go to Question 45

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

1

3

Yes
No 
If No, Go to Question 45

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

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

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

1

Yes
No

2

6

Yes
No

YOUR OVERALL EXPERIENCE WITH THE
DEPARTMENT OF VETERANS AFFAIRS

ABOUT YOU
49. In general, how would you rate your overall
health?

Now think about your experiences with all the
services provided by the Department of
Veterans Affairs (which include healthcare,
benefits programs, or memorial services).
Please tell us how you feel about the following
statements:

 Excellent
 Very good
3
 Good
4
 Fair
5
 Poor
1
2

45. I got the service I needed.







50. In general, how would you rate your overall
mental or emotional health?

Strongly disagree
Disagree

 Excellent
2
 Very good
3
 Good
4
 Fair
5
 Poor
1

Neither agree nor disagree
Agree
Strongly agree

46. It was easy to get the service I needed.







Strongly disagree

51. Are you being treated for high blood
pressure?

Disagree
Neither agree nor disagree

1

Agree

2

 Yes
 No

Strongly agree

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

47. I felt like a valued customer.







 Yes
2
 No
1

Strongly disagree
Disagree

53. Are you being treated for heart disease or
heart problems?

Neither agree nor disagree
Agree

 Yes
2
 No
1

Strongly agree

48. I trust VA to fulfill our country’s
commitment to veterans.







54. Are you deaf or do you have serious
difficulty hearing?

Strongly disagree

 Yes
2
 No
1

Disagree
Neither agree nor disagree

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

Agree
Strongly agree

 Yes
2
 No
1

7

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

62. Are you of Spanish, Hispanic, or Latino
origin or descent?
 Yes, Hispanic or Latino
 No, Not Hispanic or Latino




1

Yes
No
57. Do you have serious difficulty walking or
climbing stairs?
2

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


2


1

Yes
No
58. Do you have difficulty dressing or bathing?


2


1

Yes



No

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

64. Did someone help you complete this
survey?




1


2


Yes

2

No 
Thank you. Please return the
completed survey in the postagepaid envelope.
65. Who helped you complete this survey?

1

Yes
No
60. What is the highest grade or level of
school that you have completed?

1

 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
61. What language do you mainly speak at
home?







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

2
3
4

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

66. How did that person help you? Check all
that apply.
1
2
3

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

4

5

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 (please
print):

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

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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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