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Client Experience Questionnaire

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).

Question Title

* During your recent visit, you were a:

Patient/Resident/Client

Spouse/Family Member/Relative

Friend

Other (please specify)

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* Type of service received:

Emergency/Outpatient

Acute Hospital

Long Term Care

Community Health (Ex. Home Care, Public Health, Mental Health)

Lab & X-Ray

Other (please specify)

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* Community where services were received:

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

	Strongly Agree	Agree	Disagree	Strongly Disagree
a. I was treated with respect.	a. I was treated with respect. Strongly Agree	a. I was treated with respect. Agree	a. I was treated with respect. Disagree	a. I was treated with respect. Strongly Disagree
b. My privacy was respected as best it could be.	b. My privacy was respected as best it could be. Strongly Agree	b. My privacy was respected as best it could be. Agree	b. My privacy was respected as best it could be. Disagree	b. My privacy was respected as best it could be. Strongly Disagree
c. My cultural needs were considered.	c. My cultural needs were considered. Strongly Agree	c. My cultural needs were considered. Agree	c. My cultural needs were considered. Disagree	c. My cultural needs were considered. Strongly Disagree
d. Before providing care, staff members introduced themselves to me, where appropriate.	d. Before providing care, staff members introduced themselves to me, where appropriate. Strongly Agree	d. Before providing care, staff members introduced themselves to me, where appropriate. Agree	d. Before providing care, staff members introduced themselves to me, where appropriate. Disagree	d. Before providing care, staff members introduced themselves to me, where appropriate. Strongly Disagree
e. In general, staff were compassionate.	e. In general, staff were compassionate. Strongly Agree	e. In general, staff were compassionate. Agree	e. In general, staff were compassionate. Disagree	e. In general, staff were compassionate. Strongly Disagree

Question Title

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

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

Question Title

* Participation:
If the question does not apply, leave blank

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

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

	Strongly Agree	Agree	Disagree	Strongly Disagree
a. My care was well coordinated.	a. My care was well coordinated. Strongly Agree	a. My care was well coordinated. Agree	a. My care was well coordinated. Disagree	a. My care was well coordinated. Strongly Disagree
b. I was cared for in a timely manner.	b. I was cared for in a timely manner. Strongly Agree	b. I was cared for in a timely manner. Agree	b. I was cared for in a timely manner. Disagree	b. I was cared for in a timely manner. Strongly Disagree
c. I had access to the care I needed.	c. I had access to the care I needed. Strongly Agree	c. I had access to the care I needed. Agree	c. I had access to the care I needed. Disagree	c. I had access to the care I needed. Strongly Disagree
d. My concerns were taken seriously.	d. My concerns were taken seriously. Strongly Agree	d. My concerns were taken seriously. Agree	d. My concerns were taken seriously. Disagree	d. My concerns were taken seriously. Strongly Disagree

Question Title

* Quality:
If the question does not apply, leave blank

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

Question Title

* If the question does not apply, leave blank

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

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* Miscellaneous:
If the question does not apply, leave blank

	Strongly Agree	Agree	Disagree	Strongly Disagree
a. The facility was clean.	a. The facility was clean. Strongly Agree	a. The facility was clean. Agree	a. The facility was clean. Disagree	a. The facility was clean. Strongly Disagree
b. Overall, I was satisfied with the communication with the staff.	b. Overall, I was satisfied with the communication with the staff. Strongly Agree	b. Overall, I was satisfied with the communication with the staff. Agree	b. Overall, I was satisfied with the communication with the staff. Disagree	b. Overall, I was satisfied with the communication with the staff. Strongly Disagree
c. I felt safe.	c. I felt safe. Strongly Agree	c. I felt safe. Agree	c. I felt safe. Disagree	c. I felt safe. Strongly Disagree

Demographics: (of the patient/client/resident)

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* Gender:

Male

Female

Other

Prefer not to answer

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* Ethnicity:

Caucasian

Asian

Indigenous

African American

Central/South American

Prefer not to answer

Other (please specify)

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* Age:

0-4 years

5-9 years

10-14 years

15-19 years

20-24 years

25-29 years

30-34 years

35-39 years

40-44 years

45-49 years

50-54 years

55-59 years

60-64 years

65-69 years

70-74 years

75-79 years

80-84 years

85-89 years

90 years or older

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* Comment:

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* Do you require follow up?

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* Email Address:

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!

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

Volunteer Full Name:

Home Community:

Phone Number:

Email Address:

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* During your recent visit, you were a:

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* Type of service received:

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* Community where services were received:

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

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

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* Participation:If the question does not apply, leave blank

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

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* Quality:If the question does not apply, leave blank

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* If the question does not apply, leave blank

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* Miscellaneous:If the question does not apply, leave blank

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* Gender:

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* Ethnicity:

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* Age:

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* Comment:

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* Do you require follow up?

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* Email Address:

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* Volunteer Contact Information:

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

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

* Participation:
If the question does not apply, leave blank

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

* Quality:
If the question does not apply, leave blank

* Miscellaneous:
If the question does not apply, leave blank