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Day Surgery: Patient Experience Feedback Survey
1.
Before your procedure, did a health care professional explain what would happen to you in a way you could understand?
Definitely
For the most part
Somewhat
Not at all
Don't know/can't remember
2.
Did your Doctor or anyone from the hospital give you easy to understand instructions about getting ready for your procedure?
Definitely
For the most part
Somewhat
Not at all
Don't know/can't remember
3.
Did a health professional explain the
risks and/or benefits
in a way you could understand before your procedure?
Definately
For the most part
Not at all
I did not need or want an explanation
4.
Before your procedure, did you know who to contact if your symptoms or condition got worse?
Yes
No
5.
Did you have enough time to talk about your health condition, worries or fears with the Surgeon?
Definately
For the most part
Not at all
Don't know/can't remember
6.
Did the Surgeon listen carefully to what you had to say?
Definately
For the most part
Not at all
Don't know/can't remember
7.
If you had questions to ask the Surgeon , did you get answers that you could understand?
Definately
For the most part
Not at all
I did not need to ask
8.
If you had questions to ask the Anesthesiologist , did you get answers that you could understand?
Definately
For the most part
Not at all
I did not need to ask
9.
Did the health care professionals treating and/or examining you introduce themselves?
Yes, all of the staff introduced themselves
Some of the staff introduced themselves
Very few or none of the staff introduced themselves
Don't know/can't remember
10.
If your procedure did not start on time, how long did you have to wait?
I was seen on time or early
I waited up to 15 minutes
I waited up to one hour
I waited more than one hour
Don't know/can't remember
11.
If you had to 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
Not applicable
12.
Were you involved as much as you wanted to be in decisions about your care and treatment?
Always
Usually
Sometimes
Never
13.
How much information about your condition or procedure was given to your family, caregiver or someone close to you?
Right amount
Not enough
Too much
No family, caregiver or other person was involved
I didn't want any of them to have any information
14.
Before you left the hospital, did you have a clear understanding about all of your prescribed medications, including those you were taking before your procedure?
Definately
For the most part
Not at all
Not applicable
15.
Do you think the hospital team did everything they could to prepare you to manage your pain after you left the hospital?
Definately
For the most part
Not at all
Don't know/can't say
I did not need this information
16.
Before you left the hospital, were you told what would happen next (for example did you need a follow-up appointment)?
Definately
For the most part
Not at all
Not applicable
17.
Did you receive information about what symptoms or health problems regarding your procedure to watch for at home?
Definately
For the most part
Not at all
I did not need this information
*
18.
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
19.
Did Doctors, Nurses or other health professionals talk to you about whether you would have the help you needed at home after you left the hospital?
Definately
For the most part
Not at all
I did not need this information
20.
Overall, do you feel you were treated with dignity and respect while you were at the hospital?
Definately
For the most part
Somewhat
Not at all
21.
Canadians come from different ethnic backgrounds, religious beliefs and gender identifications. At our hospital we 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.
22.
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.
23.
Overall, at this 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
24.
Is there anything else you would like to say about this clinic experience or is there a team member or group that you would like to recognize for providing exceptional care or service?
Yes
No
If YES, please specify below:
