Skip to content

Surgery Program June 1, 2026 - December 1, 2026

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.
1.My surgery was in:
2.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.
3.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.
4.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.
5.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 Prairie Mountain Health (PMH) services and programs available to get the support I need for my health care journey.
6.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)
7.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. proper footwear, 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.
8.Surgery Program Specific Questions -
(If question does not apply, leave blank)
Yes
No
a. The surgery team (nurse, surgeon and/or assistant, anesthetist) all met with me at the same time to discuss my surgery.
b. My surgery team asked me if I had any concerns and were able to help me understand.
c. I had an opportunity to ask my surgery team questions.
d. The surgeon confirmed with me what location they were going to be operating on and/or what procedure they were going to perform.
9.Surgery Program Specific Questions -
Yes
No
e. If applicable, the surgeon marked my surgery location using a marking pen.
10.Surgery Program Specific Questions -
(If question does not apply, leave blank)
Yes
No
f. I was asked if I was having any pain.
g. I was asked if I needed something for my pain.
h. Clear written discharge instructions were given to me or my support person.
i. I was able to understand my discharge instructions.
j. In preparation for discharge home, I was given information on what to do if I required additional help.
11.Surgery Program Specific Questions -
Yes
No
N/A
k. In preparation for discharge home, arrangements were made for additional supports I might need at home.
(e.g. wound care, ostomy care, dressing change)
Demographics: (of the patient) Collected for statistical purposes only to target improvements.
12.Gender:
13.Ethnicity: 
14.Age:
15.Comments:
Forward additional concerns or compliments regarding your care to Patient Relations.
Patient Relations: email patientrelations@pmh-mb.ca or
call 1-800-735-6596


Surgery Patient Partner Volunteers Needed!! Someone just like you helped to design this survey!
We want to partner with existing Surgery patients or family members who might be interested in helping us review, design or
provide feedback to our services.


If you would like more information or if you think you might be interested in becoming a Patient Partner, please click on the link below or contact Patient Relations by calling 1-800-735-6596.

https://prairiemountainhealth.ca/forms/patient-partner/
Questions or concerns related to this survey can be sent to ceq@pmh-mb.ca

Thank you for your participation!