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, leave blank

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* What program are you currently receiving services from?

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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)
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.
e. I am aware of the Prairie Mountain Health (PMH) services and programs available to get the support I need for my health care journey.

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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, checked my wrist band, 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. 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 care.
e.  Overall, I was satisfied with the quality of care I received.

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* Mental Health Services and Addictions Services Program Specific Questions:
If the question does not apply, leave blank.

  Strongly Agree Agree Disagree Strongly Disagree
a. I would recommend the program to a friend if they were in need of similar help.
b. If I were to seek help again I would come back to this program.
c. I was actively involved in setting goals for my recovery.
d. The help I received has improved my ability to cope.
e. My health care provider focused on my strengths rather than my limitations.
f. My family and natural supports were as involved in my care as I wanted them to be.
g. I received help (for drug, alcohol, gambling and mental health concerns) as needed.
h. I felt comfortable asking questions about my care.
I. The help I received gave me hope for a positive recovery.
Demographics: (of the client) Collected for statistical purposes only to target improvements.

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* Gender:

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* Ethnicity (Race):

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* I am a newcomer to Canada (within the last 2 years)

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* Age:

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* Comments:


Mental Health & Addictions Services Patient Advisor Volunteers Needed!! Someone just like you helped to design this survey! We want to partner with existing Mental Health & Addictions Services clients 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

Questions or concerns related to this survey can be sent to ceq@pmh-mb.ca

Thank you for your participation!

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