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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* What is your main illness?

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* In which of the following settings are you receiving services?
Choose all that apply.

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* What is your primary language spoken?

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* Dignity, Respect and Trust:
(If the 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.

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* Information Sharing
(If the 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/treatments)
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.

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* Participation:
(If the 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.

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* Accessibility and Responsiveness:
(If the 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.

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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 my care.
b.My identity was confirmed before receiving care. (e.g. asked my name, asked my 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 me how to prevent falls.
d.  I felt staff were up to date on the skills needed to provide my care.
e.  In general, (as an inpatient) I was satisfied with my meals.
f.  Overall, I was satisfied with the quality of care I received.

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

  Strongly Agree Agree Disagree Strongly Disagree
a. I am satisfied with the amount of time I waited for Palliative Care Services.
b.  My health care providers make an effort to meet my individual needs.
c. My physical needs for comfort are met.
d. My health care providers give me options for pain relief when needed.
e. Emotional support is offered to me.
f. I am treated with dignity

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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:


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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