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

For purposes of this survey – the Palliative Care Client may be referred to as “your loved one”

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* What is your relationship to the Palliative Care client:

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* In which of the following settings did your family member receive services?
Choose all that apply.

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* What was the main illness of your loved one?

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  My loved one was treated with respect.
b.  My loved one's privacy was respected as best it could be.
c. My loved one's 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 my loved one/ family supports, where appropriate.
e.  In general, staff were compassionate.

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* Information Sharing
(If the question does not apply, leave blank)

  Always Usually Sometimes Never
a. Staff talked to my loved one/ family supports about what medications they are taking at home. (e.g. prescription, supplements, herbal, etc.)
b. Staff talked to my loved one/ family supports about health care options.  (e.g. procedures/tests/treatments)
c.  My loved one's health care provider used words they could understand.
d.  My loved one/ family supports had the necessary information needed to make good decisions about their health.
e.  The staff kept my loved one's information confidential and secure.

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

  Always Usually Sometimes Never
a.  Staff involved my loved one/ family supports in making decisions about their care.
b.  My loved one/ family supports were encouraged to take part in their care as much as they were able too.
c.  My loved one's/ family choices were respected.
d.  My loved one/ family supports were comfortable expressing concerns about their care.

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

  Strongly Agree Agree Disagree Strongly Disagree
a.  My loved one's care was well coordinated.
b.  My loved one was cared for in a timely manner.
c.  My loved one had access to the care they needed.
d.  My loved one's / family supports concerns were taken seriously.

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

  Always Usually Sometimes Never
a.  I saw the health care provider(s) clean their hands before providing care to my loved one.
b.  My loved one's identity was confirmed before receiving care (e.g. asked loved one's name, checked their wrist band, date
      of birth).

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

  Strongly Agree Agree Disagree Strongly Disagree
c.  Staff discussed with my loved one/ family supports how to prevent falls.
d.  I felt staff were up to date on the skills needed to provide care to my loved one.
e. If in facility, in general my family member was satisfied with the meals

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* Palliative Care - Family Program Related Questions:
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a. Overall, I was satisfied with the quality of care my loved one received.
b. My loved one/ family supports were able to talk openly with health care providers.
c. The health care providers made an effort to meet the family.
d. The health care providers did everything I expected them to do for my loved one.
e. When the need was identified, health care providers gave pain relief to my loved one.
f. My loved one's physical needs for comfort were met.
g. My loved one was treated with dignity.
h. I was offered spiritual support.
i. I was offered emotional support.
j. My loved one/ family supports were able to choose the location for end of life.
k. I received bereavement support after end of life. 

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* l.  If you did not receive bereavement support after end of life,
      what would have been helpful?

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* If you feel Palliative Care services could be improved, we welcome your suggestions:

Demographics:   (of the patient/client)

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* What is your gender?

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* Ethnicity (race):

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* What is your age?

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* Comments:

Palliative Care Program Client/Family Volunteers Needed!!  Someone just like you helped to design this survey! 
We want to partner with existing clients/family members 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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