Based on your experience in the PICU, please rank your perception of each of the following:
How are we doing right now?
How important is this?
Excellent
Above
Average
Average
Below
Average
Extremely
Poor
Very
Important
Important
Somewhat
Important
Of Little
Importance
Unimportant
Open, honest, and
clear communication
among care team
members and families.
5
4
3
2
1
5
4
3
2
1
Partnering with
families in the
decision-making and
provision of care.
5
4
3
2
1
5
4
3
2
1
Policies and programs
to promote family
involvement.
5
4
3
2
1
5
4
3
2
1
Additional Comments:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Thank you for completing this survey! Your responses will be shared with the PICU PIQME multi-disciplinary advisory group.
Please write your name & return this slip to be entered in a raffle. Two winners will be chosen each week!
Name: _____________________________________________________