Public Health
Prenatal/Postpartum Services
2020

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. 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 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 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

Question Title

* Accessibility and Responsiveness:
(If 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 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

* Quality:
(If 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. Overall, I was satisfied with the quality of care I received.	e. Overall, I was satisfied with the quality of care I received. Strongly Agree	e. Overall, I was satisfied with the quality of care I received. Agree	e. Overall, I was satisfied with the quality of care I received. Disagree	e. Overall, I was satisfied with the quality of care I received. Strongly Disagree

Question Title

* Public Health Program Specific Questions-
(If question does not apply, leave blank)

	Yes	No
a. Are you aware of how to access your local Public Health Nurse?	a. Are you aware of how to access your local Public Health Nurse? Yes	a. Are you aware of how to access your local Public Health Nurse? No
b. Were you connected with a Public Health Nurse for prenatal care?	b. Were you connected with a Public Health Nurse for prenatal care? Yes	b. Were you connected with a Public Health Nurse for prenatal care? No
c. Did you receive contact from a Public Health Nurse within 48 hours of getting home from the hospital with your baby?	c. Did you receive contact from a Public Health Nurse within 48 hours of getting home from the hospital with your baby? Yes	c. Did you receive contact from a Public Health Nurse within 48 hours of getting home from the hospital with your baby? No
d. Were you offered a home visit within 1 week of being home after the birth of your baby?	d. Were you offered a home visit within 1 week of being home after the birth of your baby? Yes	d. Were you offered a home visit within 1 week of being home after the birth of your baby? No
e. Did you feel that the Public Health Nurse supported you with your feeding goals for your baby?	e. Did you feel that the Public Health Nurse supported you with your feeding goals for your baby? Yes	e. Did you feel that the Public Health Nurse supported you with your feeding goals for your baby? No
f. Were you invited to a Child Health Clinic for your baby’s immunizations or growth and development assessment?	f. Were you invited to a Child Health Clinic for your baby’s immunizations or growth and development assessment? Yes	f. Were you invited to a Child Health Clinic for your baby’s immunizations or growth and development assessment? No
g. Was your Public Health Nurse available during convenient hours?	g. Was your Public Health Nurse available during convenient hours? Yes	g. Was your Public Health Nurse available during convenient hours? No
h. Was a Public Health Nurse available at a location that was convenient to you?	h. Was a Public Health Nurse available at a location that was convenient to you? Yes	h. Was a Public Health Nurse available at a location that was convenient to you? No
I. Did the Public Health Nurse offer or suggest resources and other services that were applicable to you?	I. Did the Public Health Nurse offer or suggest resources and other services that were applicable to you? Yes	I. Did the Public Health Nurse offer or suggest resources and other services that were applicable to you? No
j. Did your Public Health Nurse offer to review your immunization status and offer any vaccines you were eligble for?	j. Did your Public Health Nurse offer to review your immunization status and offer any vaccines you were eligble for? Yes	j. Did your Public Health Nurse offer to review your immunization status and offer any vaccines you were eligble for? No

Question Title

* k. Did your Public Health Nurse discuss the following:
(Select all that apply)

Mental Health

Substance Use

Relationships

Health Sexuality

Question Title

* Age:

Under 15 years

15-19 years

20-24 years

25-29 years

30-34 years

35-39 years

40-44 years

Over 45 years

Question Title

* Comment:

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

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

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

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

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

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

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* Public Health Program Specific Questions-(If question does not apply, leave blank)

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* k. Did your Public Health Nurse discuss the following:(Select all that apply)

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* Age:

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* Comment:

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* Volunteer Contact Information:

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

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

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

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

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

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

* Public Health Program Specific Questions-
(If question does not apply, leave blank)

* k. Did your Public Health Nurse discuss the following:
(Select all that apply)