Developing a Community-Based Patient Safety Advisory Council

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Appendix F. Meeting Evaluation

Each council member should be asked to complete an evaluation after each meeting, and meeting leaders should share the results of these evaluations at every meeting. A sample evaluation form follows.

Council Meeting Evaluation

Date: __ __ -__ __ -__ __

Scale: 1 = Strongly Disagree 3 = Agree 5 = Strongly Agree

Your input about what worked for you and what didn't is truly important to us. Please give us your feedback.

1. I was comfortable expressing my ideas and opinions.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

2. I feel the council will be effective in improving communication between patients and health care providers.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

3. I feel the council identified problems and barriers to safe medication management.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

4. I feel my participation on the council will improve my own safe medication management or the safe medication management of my patients.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

5. I feel the ideas generated today will develop into interventions to successfully improve medication safety.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

6. The facilitator(s) honored everyone's contribution and ensured we stayed on focus.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

7. The meeting's desired outcomes were achieved.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

8. I felt my time today was well spent.

1 2 3 4 5
Strongly Disagree Agree Strongly Agree

If Disagree, why?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

9. The following individual(s) or community group(s) should be part of the council:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

10. To improve future meetings, we should do the following:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

My thoughts or comments:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

If you would like to be contacted about any of your thoughts or comments, please note your name.

________________________________________________________

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