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 follow-up.

If the question does not apply, please leave blank.

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  My child was treated with respect.
b.  My child's privacy was respected as best it could be.
c.  My child'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 child, 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 about what medications my child is taking at home.  (e.g. prescription, supplements, herbal, etc.)
b.  Staff talked to me about my child's health care options.  (e.g. procedures/tests)
c.  My child's health care provider used words I could understand.
d.  I had the necessary information needed to make good decisions about my child's health.
e.  The staff kept my child's information confidential and secure.

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

  Always Usually Sometimes Never
a.  Staff involved me or my family/support system in making decisions about my child's care.
b.  I was encouraged to take part in my child's care as much as I was able.
c.  My choices were respected regarding the care of my child.
d.  I was comfortable expressing concerns about my child's care.

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  My child's care was well coordinated.
b.  My child was cared for in a timely manner.
c.  My child had access to the care he/she needed.
d.  My 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 child's care.
b.  My child's identity was confirmed before receiving care.  (e.g. asked his/her name, checked his/her wrist band, asked his/her date of birth)

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

  Strongly Agree Agree Disagree Strongly Disagree
c.  Staff discussed with my child/me how to prevent falls.
d.  I felt staff were up to date on the skills needed to provide my child's care.
e.  In general, my child was satisfied with the meals.
f.  Overall, I was satisfied with the quality of care my child received.

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* Pediatric Care Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a.  The doctor was responsive to my child's medical needs.
b.  I was given information about any follow-up needed for my child's care.
c.  I felt welcomed visiting my child at any time.
d.  I feel my feedback will be used to improve care and services.
e.  I saw the staff practicing good safety procedures to stop the spread of Covid-19 to the patients (personal protective equipment, hand washing, physical distancing).
f.  Staff talked to my child or/and  I about what we can do to keep ourselves safe from Covid-19.

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* .

  Yes No
g.  Did you participate in regular bedside reporting with the Nurse while your child was an in-patient?
Demographics:  (of the patient)

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* Gender of your child:

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* Ethnicity of your child:

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* Age of your child:

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* Comments:

Patient Advisor Volunteers Needed!!  Someone just like you helped to design this survey! 
We want to partner with existing Pediatric patients 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 below:

Question Title

* Volunteer Contact Information:


Forward additional concerns or compliments regarding your 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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