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Ambulatory Clinic: Patient Experience Feedback Survey
*
1.
Select the Hospital site you visited:
(Required.)
Alexandra Hospital Ingersoll
Tillsonburg District Memorial Hospital
2.
From the time you were first told you needed an appointment, how long did you have to wait?
Less than 1 month
4 to 6 weeks
More than 6 weeks
More than 6 months
Don't know/can't remember
3.
Did you know what to expect/what would happen to you during the appointment before you went?
Definitely
For the most part
Somewhat
Not at all
Don't know/can't remember
4.
If your appointment did not start on time, how long did you have to wait in the waiting room?
I was seen on time or early
I waited up to 15 minutes
I waited up to one hour
I waited more than one hour
Don't know/can't remember
5.
If you had to wait, were you told why?
Yes
No, but I would have liked a reason
No, but I did not mind
Don't know/can't remember
Not applicable
6.
In your opinion, how clean was the waiting area/treatment room?
Very clean
Fairly clean
Not very clean
Not at all clean
7.
Before your procedure, did a health professional explain what would happen to you in a way you could understand?
Definately
For the most part
Not at all
I did not need or want an explanation
8.
Did a health professional explain the
risks and/or benefits
in a way you could understand before your procedure?
Definately
For the most part
Not at all
I did not need or want an explanation
9.
Did you have confidence and trust in the health professional(s) you dealt with?
Definately
For the most part
Somewhat
Not at all
10.
Did the health care professionals treating and/or examining you introduce themselves?
Yes, all of the staff introduced themselves
Some of the staff introduced themselves
Very few or none of the staff introduced themselves
Don't know/can't remember
11.
Before you left the hospital, were you told what would happen next (for example did you need another appointment, did you need to see your family Doctor, will you be contacted for follow-up by a health professional)?
Definately
For the most part
Not at all
Don't know/can't remember
*
12.
Did you receive enough information from hospital team members about what to do if you were worried about your condition or treatment after you left the hospital?
(Required.)
Completely
Quite a bit
Partly
Not at all
13.
Was the main reason you went to the hospital dealt with to your satisfaction?
Definately
For the most part
Somewhat
Not at all
14.
Overall, did you feel you were treated with dignity and respect during your visit?
Definately
For the most part
Somewhat
Not at all
15.
Canadians come from different ethnic backgrounds, religious beliefs and gender identifications. At our hospital we strive to treat everyone equally, fairly and appropriately. Have you experienced any challenges in these areas? If so, your input would be appreciated.
No
Yes
If YES, please explain and offer your suggestions on how we can improve.
16.
Did you have any difficulty getting your needs met for mobility, hearing, vision or any other challenges you may have?
No
Yes
Not applicable
If YES, please describe your challenges.
17.
Overall, I had a very:
1. Poor experience
2
3
4
5
6
7
8
9
10. Good experience
1. Poor experience
2
3
4
5
6
7
8
9
10. Good experience
18.
Is there anything else you would like to say about this clinic experience or is there a staff member or group that you would like to recognize for providing exceptional care or service?
Yes
No
If YES, please specify below:
