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Acute Care Survey
Tell us about your recent hospital experience! Your feedback helps us to improve the way we provide care.
All responses are confidential and are only reported semi-annually in aggregate form.
If you have a complaint/concern about your care that requires timely follow up please contact the Patient Relations Department at
1-800-735-6596
or via email at
patientrelations@pmh-mb.ca a
s these reports are viewed bi-monthly.
*
Month of your discharge from hospital
(Required.)
January
February
March
April
May
June
July
August
September
October
November
December
*
What hospital did you visit?
(Required.)
Boissevain
Brandon
Carberry
Dauphin
Deloraine
Glenboro
Grandview
Hamiota
Melita
Minnedosa
Neepawa
Roblin
Russell
Souris
Ste. Rose
Swan River
Tiger Hills - Treherne
Tri-Lake - Killarney
Virden
Other (please specify)
If you were seen in Brandon, Dauphin, Swan River, Minnedosa or Neepawa, please indicate the ward/floor below:
Question 1
Yes
No
During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
Yes
No
Question 2
Yes
No
During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?
Yes
No
Question 3
Always
Usually
Sometimes
Never
Were you involved as much as you wanted to be in decisions about your care and treatment?
Always
Usually
Sometimes
Never
Question 4
Strongly Agree
Agree
Disagree
Strongly Disagree
Overall, I was treated with dignity and respect.
Strongly Agree
Agree
Disagree
Strongly Disagree
Question 5
Strongly Agree
Agree
Disagree
Strongly Disagree
Overall, I was satisfied with the quality of care I received.
Strongly Agree
Agree
Disagree
Strongly Disagree
Comments:
For statistical purposes, please provide patient demographic information:
Survey completed by:
Patient
Family
Friend
Other (please specify)
Gender
Male
Female
Gender Diverse
Prefer not to answer
Ethnicity (race)
Caucasian (White)
Indigenous (First Nations, Inuit, Metis)
Black
Asian (South, East)
Chinese
Filipino
Japanese
Korean
Latin American
Middle Eastern
Prefer not to answer
Other (please specify)
Age of Patient
0-4 years
5-9 years
10-14 years
15-19 years
20-24 years
25-29 years
30-34 years
35-39 years
40-44 years
45-49 years
50-54 years
55-59 years
60-64 years
65-69 years
70-74 years
75-79 years
80-84 years
85-89 years
90 years or older
Forward additional concerns or compliments regarding your care to Patient Relations.
Patient Relations: email
patientrelations@pmh-mb.ca
or call 1-800-735-6596
Patient Partner Volunteers Needed!! Someone just like you helped to design this survey!
We want to partner with existing 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!
