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

Question Title

* 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.

Question Title

* 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.

Question Title

* 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 child's choices were respected.
d.  I was comfortable expressing concerns about my child's care.

Question Title

* 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 child's concerns were taken seriously.

Question Title

* 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 name, checked wrist band, asked date of birth)

Question Title

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

  Strongly Agree Agree Disagree Strongly Disagree
c.  My child's 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 child’s care.
e.  Overall, I was satisfied with the quality of care my child received.

Question Title

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  I could easily obtain a referral for my child. 
b.  Mailed letters and forms that were sent to me were easy to read and understand.
c.  The health care provider provided information on my child’s development during the course of care. 
d.  The information provided by the health care provider was useful in allowing me to help my child between appointments. 
e.  The goals of care for my child were clear to me.
f.  The health care provider clearly explained who would receive reports and documentation related to my child. 
g.  The health care provider returned my calls in a timely manner. 
h.  I knew how to contact the health care provider if needed. 
i.  I was given information about who to talk to if I had a concern about the care provided.
j.  Attending therapy was worth our time for me and my child.
Demographics:   (of the patient)  Collected for statistical purposes only.

Question Title

* Gender:

Question Title

* Ethnicity (race):

Question Title

* Age:

Question Title

* Comments:

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

Question Title

* 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!

T