Pain Management Clinic (June 21, 2023 - December 21, 2023)

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. 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. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs)	c. My cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs) Strongly Agree	c. My cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs) Agree	c. My cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs) Disagree	c. My cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs) 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

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* 2. 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)	b. Staff talked to me about my health care options. (e.g. procedures/tests) Always	b. Staff talked to me about my health care options. (e.g. procedures/tests) Usually	b. Staff talked to me about my health care options. (e.g. procedures/tests) Sometimes	b. Staff talked to me about my health care options. (e.g. procedures/tests) 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

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* 3. 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

* 4. 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
e. I am aware of the PMH services and programs available to get the support I need for my health care journey.	e. I am aware of the PMH services and programs available to get the support I need for my health care journey. Strongly Agree	e. I am aware of the PMH services and programs available to get the support I need for my health care journey. Agree	e. I am aware of the PMH services and programs available to get the support I need for my health care journey. Disagree	e. I am aware of the PMH services and programs available to get the support I need for my health care journey. Strongly Disagree

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* 5. 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

* 6. 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.).	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.). Strongly Agree	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.). Agree	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.). 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.). 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

* 7. Pain Management Clinic Program Specific Questions-
(If question does not apply, leave blank)

	Strongly Agree	Agree	Disagree	Strongly Disagree
a. I was satisfied with the follow up to my pain management plan.	a. I was satisfied with the follow up to my pain management plan. Strongly Agree	a. I was satisfied with the follow up to my pain management plan. Agree	a. I was satisfied with the follow up to my pain management plan. Disagree	a. I was satisfied with the follow up to my pain management plan. Strongly Disagree
b. The wait time to see the pain clinic provider did not negatively affect my pain management care.	b. The wait time to see the pain clinic provider did not negatively affect my pain management care. Strongly Agree	b. The wait time to see the pain clinic provider did not negatively affect my pain management care. Agree	b. The wait time to see the pain clinic provider did not negatively affect my pain management care. Disagree	b. The wait time to see the pain clinic provider did not negatively affect my pain management care. Strongly Disagree
c. Referrals to other health care providers were offered and arranged (i.e. physiotherapy, psychology, etc.) as needed.	c. Referrals to other health care providers were offered and arranged (i.e. physiotherapy, psychology, etc.) as needed. Strongly Agree	c. Referrals to other health care providers were offered and arranged (i.e. physiotherapy, psychology, etc.) as needed. Agree	c. Referrals to other health care providers were offered and arranged (i.e. physiotherapy, psychology, etc.) as needed. Disagree	c. Referrals to other health care providers were offered and arranged (i.e. physiotherapy, psychology, etc.) as needed. Strongly Disagree
d. My emotional/psychological needs were also considered in addition to my medical care.	d. My emotional/psychological needs were also considered in addition to my medical care. Strongly Agree	d. My emotional/psychological needs were also considered in addition to my medical care. Agree	d. My emotional/psychological needs were also considered in addition to my medical care. Disagree	d. My emotional/psychological needs were also considered in addition to my medical care. Strongly Disagree

Demographics: (of the patient/client) Collected for statistical purposes only to target improvements.

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* 8. Gender:

Male

Female

Gender Diverse

Prefer not to answer

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* 9. Ethnicity:

Caucasian (White)

Indigenous (First Nations, Inuit, Metis)

Black

Asian (South, East)

Chinese

Filipino

Japanese

Korean

Latin American

Middle Eastern

Prefer not to answer

Other (please specify)

Question Title

* 10. Age:

20-24 years

25-29 years

30-34 years

35-39 years

40-44 years

45-49 years

50-54 years

55-59 years

60-64 years

65-69 years

70-74 years

75-79 years

80-84 years

85-89 years

90 years or older

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* 11. Comment:

Pain Management Clinc Patient Advisor Volunteers Needed!!
Someone just like you helped to design this survey!

We want to partner with existing Pain Management Clinic 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

* 12. Volunteer Contact Information:

Volunteer Full Name:

Home Community:

Phone Number:

Email Address:

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

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

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

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

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

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

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* 7. Pain Management Clinic Program Specific Questions-(If question does not apply, leave blank)

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* 8. Gender:

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* 9. Ethnicity:

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* 10. Age:

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* 11. Comment:

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* 12. Volunteer Contact Information:

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

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

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

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

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

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

* 7. Pain Management Clinic Program Specific Questions-
(If question does not apply, leave blank)