Number: 03-28 Effective Date: October 14, 1991 Revised: March 1, 2000 Page: 1 of 3 UNIVERSITY HOSPITALS POLICY AND PROCEDURE MANUAL _____________________________________________________________________________________ Title: Patient Complaint Management _______________________________________________________________ Prepared by: Patient Grievance Task Force and Customer Services Authorized by: Original signed by the Executive Director and the Medical Director POLICY It is the policy of The Ohio State University Hospitals to encourage inpatients, outpatients, family members, and other visitors to share their concerns and complaints. This feedback provides the Hospitals with the opportunity to resolve issues and to improve care and services. The Ohio State University Hospitals is committed to resolving complaints satisfactorily, promptly and at the first level of contact, whenever possible. It is expected that all Hospitals staff, medical staff members and volunteers will respond to patient complaints promptly and offer reasonable and appropriate solutions. A patient complaint should be discussed only with staff who has factual information and need to be aware of the issue or with those who must participate in the solution. In addition, departments shall work together in resolving complaints. The act of voicing a complaint will not jeopardize the care a patient is currently receiving, nor any future access to appropriate care. PROCEDURE A. DISSEMINATION OF INFORMATION The process for addressing patient complaints and grievances is outlined in the “Patient Rights and Responsibilities” brochure. Patients and visitors are encouraged to share their concerns with any member of the healthcare team. If a patient or visitor is unable to resolve their concerns, they may contact the Department of Customer Service. Customer Service staff will act as an advocate for the patient or visitor by representing their interests and facilitating communication with appropriate individuals within the Medical Center. Number: 03-28 Effective Date: October 14, 1991 Revised: March 1, 2000 Page: 2 of 3 UNIVERSITY HOSPITALS POLICY AND PROCEDURE MANUAL _____________________________________________________________________________________ Title: Patient Complaint Management _______________________________________________________________ B. RECEIPT OF THE COMPLAINT AND RESOLUTION PROCESS 1. Patients, family members or visitors may voice a complaint at any time. Any staff member who receives a complaint should, whenever possible, attempt to resolve it by appropriate intervention. This may include discussing the issue with staff and physicians, reviewing the chart, and consulting with others as necessary. When possible, immediate corrective action should be taken. Recognizing the complexity of some complaints, resolution may not be achieved immediately. 2. If a patient complaint relating to the clinical care rendered by the attending physician or a physician member of the treatment team is received by any staff member or volunteer, the individual should contact that physician, the attending physician, or the Office of Physician Relations for resolution of the complaint. 3. In circumstances where immediate resolution is beyond the scope of the staff member, the complaint should be reported to his/her immediate supervisor or manager for resolution. 4. If the issue cannot be resolved at this level, the supervisor or manager will then refer the complaint, with all appropriate information (individual's name, location, phone number, and the circumstances leading to the unresolved issue), to Customer Services for consultation and assistance, to the Administrator-on-Call, or, after regular business hours, to the Hospital Administrative Manager. 5. If a complaint is received in one department about another area, the receiving department should refer the complaint to that area for review and resolution. 6. Documentation of inpatient complainant issues and resolution should be documented on the Hospitals Complaint Management Form. Ambulatory care areas should document patient complaints on the Issue Documentation Form (IDF). The forms are available on the Hospital Intranet site under Staff Resources – Forms. Department complaints should be periodically reviewed to identify trends to be incorporated into the unit/department performance improvement initiatives. Number: 03-28 Effective Date: October 14, 1991 Revised: March 1, 2000 Page: 3 of 3 UNIVERSITY HOSPITALS POLICY AND PROCEDURE MANUAL _____________________________________________________________________________________ Title: Patient Complaint Management _______________________________________________________________ C. Patient Grievance Process 1. If a patient or family member has shared their complaint through the outlined processes and still feels the complaint has not been resolved or wishes to file a formal grievance, they may submit a written grievance to the Department of Customer Service requesting a review of their concerns. 2. Upon receipt of the written grievance, a grievance committee will review and investigate the grievance. The committee will consist of a representative from Customer Services, the Administrator-on-Call and the Risk Manager-on-Call. Other appropriate staff may be requested to participate in the review, depending on the nature of the grievance. 3. If the Grievance Committee finds that the complaint is related to a quality of care issue involving a physician, the Committee will immediately refer those aspects of the complaint to Quality and Operations Improvement. 4. A written response to the formal grievance will be provided to the patient within 30 days of receipt of the written grievance. D. PATIENT SATISFACTION SURVEYS Significant complaints, problems, or concerns from Patient Satisfaction Surveys will be reviewed as they are forwarded to Quality and Operations Improvement. Quality and Operations Improvement will direct these complaints to the appropriate areas for investigation in a timely manner for resolution and follow-up including a response to the patient. The response may be in person, via telephone or via letter depending upon the individual circumstances surrounding the complaint. Reports will be generated by Quality and Operations Improvement on a quarterly basis summarizing the nature of patient complaints received to assist in organizational monitoring and quality management activities. For further questions regarding the Hospitals Policy on Patient Complaint Management, contact Customer Services.
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