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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* What procedure did you have?

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* What location did you have your procedure at?

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* Prior to the date of your procedure, did you have an appointment with the doctor who performed the procedure?

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  I was treated with respect.
b.  My privacy was respected as best it could be.
c.  My 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 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 about what medications I am taking at home.  (e.g. prescription, supplements, herbal, etc.)
b.  Staff talked to me about my health care options.  (e.g. procedures/tests)
c.  My health care provider used words I could understand.
d.  I had the necessary information needed to make good decisions about my health.
e.  The staff kept my 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 care.
b.  I was encouraged to take part in my care as much as I was able.
c.  My choices were respected.
d.  I was comfortable expressing concerns about my care.

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  My care was well coordinated.
b.  I was cared for in a timely manner.
c.  I had access to the care I 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 care.
b.  My identity was confirmed before receiving care.  (e.g. asked my name, checked my wrist band, asked my date of birth)

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

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

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* Rural Endoscopy - Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a.  I received a document explaining what the test involved.
b.  I feel I received enough information to prepare for my test.
c.  I understood all parts of having a sleeping/sedative injection for the test.
d.  Before my procedure, I had an opportunity to ask my care team questions.
e.  I was informed about what was happening to me.
f.  While in hospital I was comfortable when waiting for the test.
g.  I felt that staff tried to help me keep my dignity as much as possible.

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* Rural Endoscopy - Program Specific Questions:
(If question does not apply, leave blank)

h.  I was given information on:

  Strongly Agree Agree Disagree Strongly Disagree
1.  How I will feel after my procedure.
2.  Receiving my test results.
3.  What to expect the first 24 hours following discharge.

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* Rural Endoscopy - Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
i.  Overall, I felt involved and able to participate with the care team as much as I wanted throughout my procedure (able to share concerns,  ask questions, receive information to my questions, etc.)
j.  Staff offered me pain relief and comfort.
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:

Rural Endoscopy Patient Advisor Volunteers Needed!!  Someone just like you helped to design this survey! 
We want to partner with existing Rural Endoscopy 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 in the boxes below:

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* 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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