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.  We were treated with respect.
b.  Our privacy was respected as best it could be.
c.  Our 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.

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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 my baby is taking.  (e.g. prescriptions, vitamins, etc.)
b.  Staff talked to me about my baby's health care options.  (e.g. procedures/tests)
c.  My baby's healthcare provider used words I could understand.
d.  I had the necessary information needed to make good decisions about my baby's health.
e.  The staff kept my baby's 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 baby's care.
b.  I was encouraged to take part in my baby's care as much as I was able.
c.  My choices were respected.
d.  I was comfortable expressing concerns about my baby's care.

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  My baby's care was well coordinated.
b.  My baby was cared for in a timely manner.
c.  I had access to the care my baby needed.
d.  My concerns about my baby 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 baby's health care journey.

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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 baby's care.
b.  My baby's identity was confirmed before receiving care.  (e.g. asked baby's name, checked baby's wrist band, asked baby's date of birth)

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* 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 side walks, uneven surfaces, electrical cords, etc.).
d.  I felt staff were up to date on the skills needed to provide my baby's care.
e.  Overall, I was satisfied with the quality of care that my baby received during my baby's NICU stay.
Neonatal Intensive Care Unit Program Specific Questions:
(If the question does not apply, leave it blank)

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* a.  I was satisfied with the care provided by my baby's Nurse:

  Strongly Agree Agree Disagree Strongly Disagree
1.  During my baby's admission.
2.  While infant feeding.
3.  Regarding my baby's progress in preparation for discharge.

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* b.  I was satisfied with the care provided by my baby's Pediatrician:

  Strongly Agree Agree Disagree Strongly Disagree
1.  During my baby's admission.
2.  Regarding my baby's progress in preparation for discharge.

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* Neonatal Intensive Care Unit (NICU) Program Specific Questions:
(If the question does not apply, leave it blank)

  Strongly Agree Agree Disagree Strongly Disagree
c.  Upon admission, I was given appropriate information about what to expect.
d.  I was given adequate information on infant feeding.
e.  The information given allowed me to make an informed decision about how to feed my baby.
f.  Staff assisted me to have Skin to Skin contact with my baby throughout the NICU stay when appropriate.
g.  Staff provided me information on feeding cues.  (e.g. oral cues, feeding, readiness and feeding distress cues).
h.  Staff supported me with any feeding issues/concerns.
i.  Staff provided information regarding hand expression and pumping of breast milk.
j.  Staff provided information regarding establishing/maintaining my milk supply.
k.  I was welcome to visit my baby at any time.

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* l.  I found these booklets to be helpful:

  Strongly Agree Agree Disagree Strongly Disagree
1.  "Welcome to NICU"
2.  "Feeding your baby"
3.  "Preparing for discharge Home from NICU"

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* Neonatal Intensive Care Unit (NICU) Program Specific Questions:
(If the question does not apply, leave it blank)

  Strongly Agree Agree Disagree Strongly Disagree
m.  I was given enough information on available supports after discharge (e.g. Public Health, Occupational Therapy, Physical Therapy, Mental Health, Breastfeeding Support).
n.  Overall, I was satisfied with the quality of care that my baby received during the NICU stay.

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* Neonatal Intensive Care Unit (NICU) Program Specific Questions:
(If the question does not apply, leave it blank)

  Yes No
o.  I was seen by the Lactation Consultant while my baby was in NICU (as appropriate).
Demographics:   (of the patient) Collected for statistical purposes only to target improvements.

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* Gender:

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* Ethnicity (Race):

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* Why was your baby admitted to the NICU?

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* Comments:

NICU Patient Advisors Needed!!  Someone just like you helped to design this survey! 
We want to partner with existing or previous NICU patients/parents 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 in the boxes below:

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* 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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