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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* 1. I learned about the 7th Street Health Access Centre from:

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* 2. I used the following services at the 7th Street Health Access Centre: 
(Check all that apply)

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* 3. I saw the following PMH staff resources:  
(Check all that apply)

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* 4. I was given information about other supports/programs available in the community:

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* 5. The information of services I was given helped me to improve my situation:

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* 6. 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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* 7. 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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* 8. 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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* 9. 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.
e.  I am aware of the PMH services and programs available to me.

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* 10. 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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* 11. 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 sidewalks, 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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* 12. 7th Street Health Access Centre Program Specific Questions-
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a. I was happy with the length of time it took to be seen from the day of my request to appointment day.
b. I felt safe while visiting the 7th Street Health Access Centre.
c. 7th Street Health Access Centre staff made me feel welcome.
d. In general, I felt the staff I met with explained the services they could provide to me.
e. In general, I felt the staff I met with made me feel comfortable during my appointment.
f. In general, I felt the staff I met with treated me fairly.
g. After my appointment, I knew what to do when I left 7th Street Health Access Centre.
h. I will continue to use services available at the 7th Street Health Access Centre.
Demographics: (of the patient/client) Collected for statistical purposes only to target improvements.

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* 13. Gender:

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* 14. Ethnicity: 

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* 15. Age:

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* 16. Comment:

7th Street Health Access Centre Patient Advisor Volunteers Needed!! 
Someone just like you helped to design this survey! 
We want to partner with existing 7th Street Health Access Centre 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:

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* 17. 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

 Questions or concerns related to this survey can be sent to ceq@pmh-mb.ca 


Thank you for your participation! 

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