Date: ____/____/____                     Time: ________ AM/PM

Patient group: ___________________________________________

Facilitator: ______________________________________________

Facilitator Title: __________________________________________

1.    What were the most important events during your hospital stay?

2.    What were the most positive?

3.    Where there any negative events during your hospital stay?

• How would you have changed it, or how would you have like to have seen it go?

4.    Did you receive enough information to make informed decisions?

• Was the information presented in such a way that it was understandable?
• What would you change?

5.    How much of their time is down time and how would they rather use it?

6.    What type of issues/events during the patient's stay could be categorized as redundant or repetitive and how this affected the stay?

7.    How the patient may want to be engaged in the process of care?

8.    What types of information would you like to have access to, that would improve your stay?

9.    How would the patient like to use technology such as E-mail?

10.  Do you or your family wish to take part in your care?  How would you like to participate?

• Eat in a cafeteria.
• Walk to other departments for tests/x-rays.
• Assist with bathing activities.
• Would you like to have access to your chart?

If your care provider spoke your native language would you trust them more or less than someone who needs a translator?

Notes: