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Page One

Patient and Families as Partners 2 – Post Meeting Feedback

1. Facility name: *This question is required.

2. Your email: *This question is required.

3. Initiative: *This question is required.

4. Which of the following best describes your primary role on the improvement team: *This question is required.

5. Did your PQIT have a team meeting this month? *This question is required.

6. Did you attend your PQIT’s meeting this month? *This question is required.

6. Did any patients/family members participate in the meeting? *This question is required.

Yes, in-person
Yes, by phone
Yes, by reviewing materials through email
No

6. How many patients/family members participated in the meeting? *This question is required. This question requires a valid number format.

Each of the below questions should be answered on a 7-point Likert scale:

1 – Strongly disagree
2 – Disagree
3 – Somewhat disagree
4 – Neither agree or disagree
5 – Somewhat agree
6 – Agree
7 – Strongly agree

6. During the meeting: *This question is required.

Space Cell	1	2	3	4	5	6	7
The patient/family perspective was respected.	The patient/family perspective was respected.: 1	The patient/family perspective was respected.: 2	The patient/family perspective was respected.: 3	The patient/family perspective was respected.: 4	The patient/family perspective was respected.: 5	The patient/family perspective was respected.: 6	The patient/family perspective was respected.: 7
Patients/family members appeared properly prepared to participate.	Patients/family members appeared properly prepared to participate.: 1	Patients/family members appeared properly prepared to participate.: 2	Patients/family members appeared properly prepared to participate.: 3	Patients/family members appeared properly prepared to participate.: 4	Patients/family members appeared properly prepared to participate.: 5	Patients/family members appeared properly prepared to participate.: 6	Patients/family members appeared properly prepared to participate.: 7
Patients/family members appeared comfortable asking questions.	Patients/family members appeared comfortable asking questions.: 1	Patients/family members appeared comfortable asking questions.: 2	Patients/family members appeared comfortable asking questions.: 3	Patients/family members appeared comfortable asking questions.: 4	Patients/family members appeared comfortable asking questions.: 5	Patients/family members appeared comfortable asking questions.: 6	Patients/family members appeared comfortable asking questions.: 7
Patient/family engagement was supported and encouraged by the team.	Patient/family engagement was supported and encouraged by the team.: 1	Patient/family engagement was supported and encouraged by the team.: 2	Patient/family engagement was supported and encouraged by the team.: 3	Patient/family engagement was supported and encouraged by the team.: 4	Patient/family engagement was supported and encouraged by the team.: 5	Patient/family engagement was supported and encouraged by the team.: 6	Patient/family engagement was supported and encouraged by the team.: 7
A plan was developed including next steps and action items to be completed by team members.	A plan was developed including next steps and action items to be completed by team members.: 1	A plan was developed including next steps and action items to be completed by team members.: 2	A plan was developed including next steps and action items to be completed by team members.: 3	A plan was developed including next steps and action items to be completed by team members.: 4	A plan was developed including next steps and action items to be completed by team members.: 5	A plan was developed including next steps and action items to be completed by team members.: 6	A plan was developed including next steps and action items to be completed by team members.: 7
A plan was developed that was, in part, a product of patient/family feedback.	A plan was developed that was, in part, a product of patient/family feedback.: 1	A plan was developed that was, in part, a product of patient/family feedback.: 2	A plan was developed that was, in part, a product of patient/family feedback.: 3	A plan was developed that was, in part, a product of patient/family feedback.: 4	A plan was developed that was, in part, a product of patient/family feedback.: 5	A plan was developed that was, in part, a product of patient/family feedback.: 6	A plan was developed that was, in part, a product of patient/family feedback.: 7
A plan was developed that included tasks to be completed by patients/family members.	A plan was developed that included tasks to be completed by patients/family members.: 1	A plan was developed that included tasks to be completed by patients/family members.: 2	A plan was developed that included tasks to be completed by patients/family members.: 3	A plan was developed that included tasks to be completed by patients/family members.: 4	A plan was developed that included tasks to be completed by patients/family members.: 5	A plan was developed that included tasks to be completed by patients/family members.: 6	A plan was developed that included tasks to be completed by patients/family members.: 7