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

Department(s): ________________________________________________________________________________

1.    Are there parts of your job that you think someone else should be doing instead of you?

2.    Are there things you think should be part of your job that someone else is doing?

3.    What are the things that keep you from working efficiently?

4.    Are there things you see happening to patients that you think you should tell someone but you don't know whom to tell?

5.    Given what you see every day, if you were a patient in the hospital what would you want to be different?

6.    What things would you want to do for yourself if you were a patient? What things would you want your family to be able to do?

Notes: