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Emergency Department (ED): Patient Experience Feedback Survey
*
1.
Select the Hospital site you visited:
(Required.)
Alexandra Hospital Ingersoll
Tillsonburg District Memorial Hospital
2.
What was the main reason you came to the Emergency Department (ED)?
An accident or injury
A new health problem
An ongoing health condition or concern
3.
When you first arrived at the ED, how long was it before someone talked to you about the reason you were here?
Less than 5 minutes
5 to 15 minutes
More than 15 minutes
4.
Did Nurses treat you with courtesy and respect?
Always
Usually
Sometimes
Never
5.
Did Nurses listen carefully to you?
Always
Usually
Sometimes
Never
6.
Did Nurses explain things in a way that you could understand?
Always
Usually
Sometimes
Never
7.
Did Doctors treat you with courtesy and respect?
Always
Usually
Sometimes
Never
8.
Did Doctors listen carefully to you?
Always
Usually
Sometimes
Never
9.
Did Doctors explain things in a way that you could understand?
Always
Usually
Sometimes
Never
10.
Do you feel there was good communication about your care between Doctors, Nurses and other hospital staff?
Always
Usually
Sometimes
Never
Don't know/not sure
11.
Did care providers help to ease your discomfort, pain or symptoms?
Yes
Yes, mostly
Yes, somewhat
No
Not applicable
12.
Did you get the support you needed to help you with any anxieties, fears or worries you had during this ED visit?
Always
Usually
Sometimes
Never
Not applicable
13.
Before you left the ED, if given any new medications, did a Doctor or Nurse explain what the medication was for?
Yes, definately
Yes, somewhat
No
Not applicable
*
14.
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
15.
If you did not answer "Completely" to #14. above, what additional information was missing?
Medications
Follow-up appointments
Education related to diagnoses or visit
What to expect once home
Who to call with any questions/concerns
Other
Other (please specify)
16.
Overall, how long did your visit to the ED last?
Less than 1 hour
1-3 hours
3-6 hours
6-12 hours
12-24 hours
Greater than 24 hours
17.
Did team members provide communication or updates about your wait time?
Always
Usually
Sometimes
Never
18.
If you had a long 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
I did not have a long wait
19.
Canadians come from different ethnic backgrounds, religious beliefs and gender identifications. At our hospital were 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:
20.
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.
21.
Overall, do you feel you were helped by your hospital ED visit?
1. Not at all
2
3
4
5
6
7
8
9
10. Helped Completely
1. Not at all
2
3
4
5
6
7
8
9
10. Helped Completely
22.
Overall, at this ED visit 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
23.
Is there anything else you would like to say about this ED experience? (Please do not include any names, contact or identifying information.)
Yes
No
If YES, please comment:
