HospitalInspections.org

Based on a review of the hospital policy "Patient Complaints and Grievances Management" policy (revised 07/14), it is revealed that the hospital's policy for the handling of complaints and grievances does not clearly differentiuiate when a concern should be mangedas a grievance.

The hospital Patient Complaints and Grievances Management policy defines complaints as "A verbal expression of dissatisfaction or allegation of a wrong committed one of the following categories:
- Clinical quality (timelines, effectiveness, adequacy, appropriateness)
- Service quality (lack of services, rudeness, accessibility issues)
- Accommodations (cleanliness, room temperature, noise level, food, privacy, safety, telecommunication).
- Access to medical records
- Lost/stolen valuables
- Patient rights (harassment, interpretation services, advance directives, consent issues, access to social work/pastoral care/patient advocates/privacy/confidentiality)
Billing issues (with no additional comment included)
All social media communications

Based on this list (excluding billing) which the hospital defines as complaints, the hospital has not clearly defined potential types of grievances, particularly, but not limited to, clinical quality; service quality; accommodations as related to cleanliness, food, privacy, and safety; access to medical records, lost/stolen valuables; and, all patient rights issues that msut be addressed more formally.

Based on a review of the hospital Patient Complaint and Grievances policy, and 10 random grievance files, it is determined that the policy failed to provide for a contact person in its letter of resolution; and for 10 of 10 grievance files reviewed, the hospital policy failed to give written determinations of the hospital decision to the grievant.


The hospital policy "Patient Complaints and Grievances" (revised 07/14) stated in part, " The written resolution letter to the complaint includes the steps taken to investigate the grievance, the results of the investigation and the date of completion." Additionally, the policy stated "If the grievance has not been resolved within 30 days, the patient/family will be given the name and contact information of the staff member they can contact regarding the grievance .... " Based on this information, the policy failed to name a hospital contact person in any resolution letter sent within hospital general grievance timelines, and offers contact information only for grievance investigations outside of general timelines.


Interview with the patient experience representative on 7/27/2016 at approximately 1330, revealed her understanding that hospital grievance resolutions could be communicated to grievants in the same manner by which the grievance was received. This included the representative's belief that in-person verbal, and phone communications were appropriate.


A review of 10 randomly selected grievance files revealed no written hospital grievance decisions were made or sent for 10 of 10 grievances reviewed. Based on this, the hospital failed to meet regulatory requirements for resolution letters.