Critical Care Family Member Survey

We hope that you received outstanding care during your stay in a Methodist Hospital critical care unit. We believe that family members should also have a positive experience. If possible, we would like this survey to be filled out by the family member or friend who was with you in the hospital the most. We want your ideas, opinions, and comments. We will use the information you provide in this survey to create a more patient- and family-centered environment. Please read each question, and mark the one response that best describes your experience. After you complete the survey please return it in the postage paid envelope, at your earliest convenience.

Todays Date: ____________________

Background Information
Critical Care Area (If you were in more than one critical care unit please rate the unit where you were treated the longest): ___ Medical ICU ___ Surgical ICU ___ Cardiovascular ICU ___ Neuro ICU ___ Transplant ICU

Physician(s) who was primarily responsible for coordinating care: _____________________________________________________________________________________________________________

Communication
Always 1. Results from tests, procedures and treatments were explained to me in a way I could understand 2. I felt comfortable enough to ask the staff all of my questions 3. The nurses were available to speak with me about my family members care 4. The doctors were available to speak with me about my family members care Usually Sometimes Rarely Never Not Applicable

A A

U U

S S

R R

N N

N/A N/A

N/A

N/A

Quality of Care
Always 5. The staff did everything they could to manage my family members pain A Excellent 6. The overall quality of care given to my family member
E

Usually U Very Good

VG

Sometimes S Good
G

Rarely R Fair
F

Never N Poor
P

Not Applicable N/A Not Applicable

N/A

Definitely Yes 7. Overall, were you treated well during your visit with us? DY

Probably Yes PY

Maybe M

Probably No PN

Definitely No DN

Empathy
Always 8. I was supported by the staff during my family members stay in the critical care unit 9. The staff provided spiritual and/or emotional support to me and my family members 10. Privacy was provided for me/my family members during our stay
PS003586.1210 REV

Usually U

Sometimes S

Rarely R

Never N

Not Applicable N/A

A A

U U

S S

R R

N N

N/A N/A

Participation
Always 11. I was able to participate in the care of my family member 12. I was able to participate in decisions regarding my family members care 13. I was able to participate in discussions regarding my family members recovery A A Usually U U Sometimes S S Rarely R R Never N N Not Applicable N/A N/A

N/A

Responsiveness
Always 14. The staff was prompt in responding to alarms and requests for assistance Usually Sometimes Rarely Never Not Applicable

N/A

Environment
Always 15. The family (waiting) room was clean 16. The family (waiting) room was comfortable A A Usually U U Sometimes S S Rarely R R Never N N Not Applicable N/A N/A

If your loved one received Palliative Care, please continue with the next section. If not, please go to the Comments Section.

Palliative Care
Always 17. The Palliative Care Team respected me/my family 18. The Palliative Care Team provided emotional support to me/my family 19. The Palliative Care Team kept me informed about my family members condition 20. I had confidence and trust in the Palliative Care Team A A Usually U U Sometimes S S Rarely R R Never N N Not Applicable N/A N/A

A A

U U

S S

R R

N N

N/A N/A

Comments
If we have further questions about your experience, may a representative from this hospital call you to discuss them? ___ No ___ Yes If yes, Name: _____________________________________________Phone number:______________________ Please list the names of any staff members that you would like to recognize for providing outstanding care. ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ What could this hospital have done to make the experience for you and other friends or family even better? ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Thank you for taking the time to fill out this survey. Please place the survey in the enclosed envelope or mail it to Superior Dataworks, 340 Poplar View Lane East, Ste. 1, Collierville, TN 38017
ST: 11 Fac: 1 Unit: Medical (136); Surgical (134); Cardiovascular (132) Neuro (133); Transplant (135) IP Service: 30