Client Experience Questionnaire

Tell us about your experience!  Your feedback helps us to improve the way we provide care.  This questionnaire was built upon our Patient Values (Dignity, Respect and Trust, Information Sharing, Participation, Accessibility and Responsiveness, and Quality).

We do not collect personal information unless you request a follow-up.

If the question does not apply, please leave blank

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* Your relationship to the Intensive Care Unit (ICU) Client:

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* Dignity, Respect and Trust:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a.  My family member was treated with respect.
b.  My family member’s privacy was respected as best it could be.
c.  My family member’s cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs)
d.  Before providing care, staff members introduced themselves to my family member/me, where appropriate.
e.  In general, staff were compassionate.

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* Information Sharing:
(If question does not apply, leave blank)

  Always Usually Sometimes Never
a.  Staff talked to me/my family member about what medications they were taking at home. (e.g. prescription, supplements, herbal, etc.)
b.  Staff talked to me/my family member about their health care options.
c.  The health care provider used words we could understand.
d.  My family member/I had the necessary information needed to make good decisions about their health.
e.  Staff kept my family members information confidential and secure.

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* Participation:
(If question does not apply, leave blank)

  Always Usually Sometimes Never
a.  Staff involved us in making decisions about my family member’s care.
b.  My family member was encouraged to take part in their care as much as they were able.
c.  My family member’s choices were respected.
d.  I/my family member was comfortable expressing concerns about my loved one’s care.

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* Accessibility and Responsiveness:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a.  My family member’s care was well coordinated.
b.  My family member was cared for in a timely manner.
c.  My family member had access to the care they needed.
d.  Our concerns were taken seriously.

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* Quality:
(If question does not apply, leave blank)

  Always Usually Sometimes Never
a.  I saw the health care provider(s) clean their hands before providing my family members' care.
b.  My family member’s identity was confirmed before receiving care. (e.g. asked name, checked wrist band, asked date of birth)

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* Quality:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
c.  My family members' healthcare provider discussed risks or hazards that could cause falls/slips/trips. (e.g. wet floors, icy side walks, uneven surfaces, electrical cords, etc.)
d.  I felt staff were up to date on the skills needed to provide my family member’s care.
e.  Overall, I was satisfied with the quality of care my family member received.

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* Brandon ICU - Family Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a.  The pamphlet(s) made available to me/my family were helpful in understanding the care provided in the ICU.
b.  The physical space my family member was in, provided a safe environment (e.g. comfortable, private, safe from harm).
c.  Family members were told when physician rounds were.
d.  If you were present during the rounds, you/other family member’s were able to participate.
e.  I felt the visiting hours were reasonable.
f.  The number of visitors allowed at a time met my loved one’s needs.
g.  My family member’s emotional needs were met during their stay in the ICU.
h.  My family member’s pain was well managed by the health care team.
i.  In general,  my family member was satisfied with their meals.

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* Brandon ICU - Family Program Specific Questions:
(If question does not apply, leave blank)

j.  I was satisfied with the quality of care provided to my family member by the:

  Strongly Agree Agree Disagree Strongly Disagree
1. Social Worker
2. Spiritual/ Pastoral Care
3. Therapy
4. Other (please specify below)

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* Brandon ICU - Family Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
k.  During the final hours of my family member’s life, the staff honored my family member’s wishes.
l.  During the final hours of my family member’s life, the staff honored my wishes.
m.  During the final hours of my family members life, I felt that my loved one was comfortable.
n.  During the final hours of my family members life, I felt supported by the health care team.
Demographics:   (of the patient)  Collected for statistical purposes only.

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* Gender:

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* Ethnicity (race):

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* Age:

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* Comments:

Brandon ICU Patient/ Family Advisor Volunteers Needed!!  Someone just like you helped to design this survey! 
We want to partner with Brandon ICU families who might be interested in helping us review, design or
provide feedback to our services. 
If you are interested in this, please leave your name, phone number and email address in the boxes below:

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* Volunteer Contact Information:


Forward additional Concerns or Compliments regarding your loved one's care to Patient Relations.

Patient Relations email:  patientrelations@pmh-mb.ca or call  1-800-735-6596

Thank you for your participation!

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