Acute Care Survey

Tell us about your recent hospital experience! Your feedback helps us to improve the way we provide care.

All responses are confidential and are only reported semi-annually in aggregate form.

If you have a complaint/concern about your care that requires timely follow up please contact the Patient Relations Department at 1-800-735-6596 or via email at patientrelations@pmh-mb.ca as these reports are viewed bi-monthly.

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* Month of your discharge from hospital

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* What hospital did you visit?

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* If you were seen in Brandon, Dauphin, Swan River, Minnedosa or Neepawa, please indicate the ward/floor below:

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* Question 1

	Yes	No
During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?	During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Yes	During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? No

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* Question 2

	Yes	No
During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?	During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? Yes	During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? No

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* Question 3

	Always	Usually	Sometimes	Never
Were you involved as much as you wanted to be in decisions about your care and treatment?	Were you involved as much as you wanted to be in decisions about your care and treatment? Always	Were you involved as much as you wanted to be in decisions about your care and treatment? Usually	Were you involved as much as you wanted to be in decisions about your care and treatment? Sometimes	Were you involved as much as you wanted to be in decisions about your care and treatment? Never

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* Question 4

	Strongly Agree	Agree	Disagree	Strongly Disagree
Overall, I was treated with dignity and respect.	Overall, I was treated with dignity and respect. Strongly Agree	Overall, I was treated with dignity and respect. Agree	Overall, I was treated with dignity and respect. Disagree	Overall, I was treated with dignity and respect. Strongly Disagree

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* Question 5

	Strongly Agree	Agree	Disagree	Strongly Disagree
Overall, I was satisfied with the quality of care I received.	Overall, I was satisfied with the quality of care I received. Strongly Agree	Overall, I was satisfied with the quality of care I received. Agree	Overall, I was satisfied with the quality of care I received. Disagree	Overall, I was satisfied with the quality of care I received. Strongly Disagree

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* Comments:

For statistical purposes, please provide patient demographic information:

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* Survey completed by:

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* Gender

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* Ethnicity (race)

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* Age of Patient

Patient Partner Volunteers Needed!! Someone just like you helped to design this survey!
We want to partner with existing patients or family members who might be interested in helping us review, design or provide feedback on our care, services or buildings.

By leaving your name, phone number and email address below, you are indicating your interest in partnering with Prairie Mountain Health (PMH) and are consenting to be contacted by Patient Relations.
Patient Relations will be in contact with you when an opportunity becomes available.

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* Volunteer Contact Information:

Volunteer Full Name:

Home Community:

Email Address:

Phone Number:

Thank you for your participation!