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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* Name of Long Term Care Home:

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* Survey Completed by:

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

  Always Usually Sometimes Never
a.  When I was admitted to the Personal Care Home (PCH)/Transitional Unit (TU) staff talked to me about what medications I was 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 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 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 question does not apply, leave blank)

  Always Usually Sometimes Never
a. I saw the healthcare 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 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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* Long Term Care Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a. Upon admission, staff and other residents were introduced to me.
b. Staff address me by my preferred name.
c. Staff speak to me in a language I could understand.
d. Staff respect my individual rights as a resident.
e. Me and/or my family feel welcome to participate in Resident Council Meetings.
f. There are a variety of activities offered.

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* What additional activities would you like to see?

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* Long Term Care Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
g. I enjoy participating in activities.

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* If you Strongly Agree or Agree, what activities do you enjoy?

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* Long Term Care Program Specific Questions:
(If question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
h. I feel my facility offers a home like environment.
i. I am able to provide input into decisions that are made in the home (e.g. paint colors, furniture selection etc.).
j. I feel my home is clean and odor free.
k. I felt confident that the staff tried their best to keep me safe from illness.
Demographics: (of the resident) Collected for statistical purposes only.

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* Gender:

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* Ethnicity (race):

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* Age:

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* Comments:

Patient Partners Needed! Someone just like you helped to design this survey!
We want to partner with existing Long Term Care residents or their loved ones who might be interested in helping us review,
design or provide feedback to our services.

By leaving your name, phone number and email address below, you are indicating your interest in partnering with Prairie Mountain Health (PMH) and are consenting to be contacted by Patient Relations.
Patient Relations will be in contact with you when an opportunity becomes available.

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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!