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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* 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.
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/treatments)
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.  Staff discussed with me how to prevent falls
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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* Midwifery Program Specific Questions-
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a. There was good communication between the midwife and other health care providers involved in my care.
b. I received the same information from all the midwives who provided care to me.
c. My midwife explained all clinical procedures beforehand.
d. I felt my midwife understood my health concerns related to my pregnancy.
e. I got a prompt response from the midwife whenever I paged.
f. I was familiar with the midwife who attended my delivery.
g. I felt involved in decision making throughout my labor.
h. I felt I had the opportunity to birth in the way I wanted.
I. I felt supported after the birth of my baby.
Demographics:  (of the patient)

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* Who completed survey?

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* Ethnicity

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* Age:

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* Comment:

Midwifery Patient Advisor Volunteers Needed!!  Someone just like you helped to design this survey! 
We want to partner with existing Midwifery 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:


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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