William Bee Ririe Critical Access Hospital and Rural Health Clinic
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Complaints
Concern/Complaints

POLICY

It is WBRH's intent to respond to all documented Patient/Visitor concerns and grievances in an assertive, professional, systematic manner, to continuously improve quality patient care and patient satisfaction. 


PROCEDURE

Systematic Concern Procedure: 

1. Patents/Visitors who have a concern may document said concern on the Patient Concern Form. Additionally, an employee or other interested party may complete the Patient Concern Form on the patients' behalf. 

2. All Patient Concern Form(s) should be forwarded to the Public Relations Director. The Public Relations Director is responsible, within 1 business day, to provide the department manager(s) a copy of the Patient Concern Form. 

3. The department manager(s) are responsible for performing a cause analysis and respond to the Patient Concern Form within 10 business days. Response can be done in-person, via phone, or through the mail. If deemed necessary, the Public Relations Director has the authority to extend the 10 business day requirement. If an extension is necessary, the department manager(s) must contact the Public Relations Director within the 10 business day time frame with information as to why an extension is necessary. If formal follow up needs to be extended for some reason, patient will be contacted to be given an update as to the current status of their Patient Concern/Complaint and an expected time frame for completion. 

4. Manager(s) will be provided identifying information about whom, when, where, and what, to perform an appropriate root cause analysis. Exception to this can be made if additional confidentiality is requested by the person submitting the Patient Concern Form, at which time the Public Relations Director will use a number in place of a name. A copy of all numbers associated with patient names will be given to the CEO. If adequate information is not available for the manager(s) to perform a root cause analysis, the Public Relations Director will informally discuss the concern with the manager(s) and the manager(s) is not required to provide a formal response. The concern will not be included in the quality assurance evaluation and monitoring studies. In cases in which numbers have been substituted for names, if all other conditions are met for concern to be investigated, department managers are required to provide a written response to the complaint that can be mailed to the patient by the Public Relations Director or CEO. 

5. The Chief of Staff or physician designated by the Medical Staff will review concerns regarding a physician. The Vice-Chief of Staff, designated physician, or Medical Staff Peer Review will review any concerns regarding the Chief of Staff. Concerns regarding a physician's or mid-level practitioner's quality of care or premature discharge from the hospital shall be forwarded to the Medical Staff Peer Review Committee, directly accountable to the Medical Staff. 

6. Patient follow up is required unless the patient requests the follow up not be done. If follow up needs to be extended for some reason, patient will be contacted to be given an update as to the current status of their Patient Concern and an expected time frame for completion. 

7. The Public Relations Director, as part of an ongoing quality assurance study, is responsible for evaluating and monitoring patient concern information. If available, the Public Relations Director is responsible for benchmarking data with other hospitals. The Public Relations Director will provide the CEO with a Patient Satisfaction Quality Assurance Report each month. Additionally, the Public Relations Director, after reviewing the report with the CEO, is responsible for reviewing the Patient Satisfaction Quality Assurance Report findings with appropriate department manager(s) and/or physician(s) on a monthly or next scheduled meeting basis. 

8. The Public Relations Director is responsible for maintaining a Patient Notification Procedure which includes appropriate patient information regarding William Bee Ririe Hospital notification requirements and grievance process. Department managers will assure Patient/Visitor Concern Forms are available for patient access in their department and that Patient Notification Procedure forms are included in all mailed responses to Patient/Visitor Concern forms. If the person is contacted in person or by phone, department managers must inform the person of the Patient Notification Procedure forms and ask if the person would like those mailed. If the person requests a copy of those forms, it is the responsibility of the department manager to mail those within the 10 business day time frame. 

9. The notification and answer to a concern, by the department manager, to a patient, is to include the name of the hospital, the steps taken on behalf of the patient to investigate the concern, the results of that investigation, and the date of completion. The notice will be in a language or manner understood by the person that submitted the concern or their legal representative. Department managers will also provide this information to the Public Relations Director within the 10 business day time frame. 

10. All patient/visitor complaints must go through the Concern Process before the Grievance Process unless there may be legal ramifications associated with the concern/complaint. 


Systematic Grievance Procedure: 

1. Patents/Visitors who have been through the Concern Procedure and would like further review of their concern may document said concern on the Patient/Visitor Grievance Form. Additionally, an employee or other interested party may complete the Patient/Visitor Grievance Form on the patients' behalf. 

2. All Patient Grievance Form(s) should be forwarded to the Public Relations Director within 1 business day of receipt. The Public Relations Director is responsible, within 1 business day of receipt, to inform department managers of a grievance that has been filed in relation to their department. 

3. The department manager(s) are responsible for providing the documentation supporting the completed Patient/Visitor Concern Form to the Public Relations Director within 2 business days, if the information has not already been provided. If additional investigation is warranted, the Public Relations Director or CEO may ask the department manager(s) to provide information for the investigation. The department manager(s) will have 5 business days to provide the information requested. 

4. Manager(s) will be provided identifying information about whom, when, where, and what, as necessary to gather information, if any information is requested by the Public Relations Director or CEO. Exception to this can be made if additional confidentiality is requested by the person submitting the Patient Grievance Form, at which time the Public Relations Director will use a number in place of a name. A copy of all numbers and patient names will be given to the CEO. 

5. The Public Relations Director, after reviewing the department manager(s) response to the Patient Concern Form, is responsible for reviewing the grievance with the CEO. 

6. The Chief of Staff or physician designated by the Medical Staff will review concerns regarding a physician. The Vice-Chief of Staff, designated physician, or Medical Staff Peer Review will review any concerns regarding the Chief of Staff. Concerns regarding a physician's or mid-level practitioner's quality of care or premature discharge from the hospital shall be forwarded to the Medical Staff Peer Review Committee, directly accountable to the Medical Staff. 

7. The Public Relations Director, after obtaining CEO approval, will perform written patient follow up. Time frames to follow up with the patient will be no longer than 30 days after receipt of the Patient/Visitor Grievance Form. Patient follow up is required, unless the patient requests the follow up not be done. If formal follow up needs to be extended, the person will be contacted to be given an update as to the current status of their Patient Grievance and an expected time frame for completion. 

8. The Public Relations Director, as part of an ongoing quality assurance study, is responsible for evaluating and monitoring patient grievance information. If available, the Public Relations Director is responsible for benchmarking data with other hospitals. Grievances will be included in the Patient Satisfaction Quality Assurance Report. 

9. The written notification and answer to a concern, by the Public Relations Director, to a patient or visitor, is to include the name of the hospital, the steps taken on behalf of the patient to investigate the grievance, the results, and the date of completion. The written notice will be in a language or manner understood by the patient or legal representative and will include the Patient Notification Procedure Form. 

Grievance Committee 

A Grievance Committee will be responsible for reviewing and overseeing any changes in the policies or procedures as a result of a grievance. This committee will consist of the Chief Executive Officer, Chief of Staff, Hospital Director of Nursing, Risk Manager, and Public Relations Director. The Public Relations Director, will review grievances and investigations, with the Grievance Committee, as necessary. 

1. The Public Relations Director will obtain as much information as possible from the patient and will provide this information to all committee members for review. 

2. Practitioner issues are those that involve any aspect of care provided by an individual who has been granted privileges by the hospital, including complaints about disruptive behavior. The concern shall be investigated and corrective action determined consistent with the Medical Staff peer review process. A written report of the actions shall be submitted to the Grievance Committee for review and recommendations, if necessary. 

3. Hospital issues are those that involve any aspect of services provided by the hospital except the care provided by practitioners. These complaints will be referred to the manager responsible for the area. Actions shall be reported to the Grievance Committee for review and recommendations. 

Confidentiality 

The Risk Manager will be responsible for maintaining all minutes, reports, recommendations, communications and actions made or taken pursuant to this policy that are deemed to be covered by the provisions of N.R.S. 49.265 in accordance with Medical Staff By-Laws and Peer Review Process. 

Furthermore, the department directors, committees and/or panels charged with making reports, findings, recommendations, or investigations pursuant to this policy shall be considered to be acting on behalf of the Hospital Medical Staff and Hospital Board of Directors when engaged in such professional review activities and thus shall be deemed to be "profession review bodies" as that term is defined by the Healthcare Quality Improvement Act of 1986. The Quality Assurance-Performance Improvement Manager will maintain, in secured files, the investigation including root cause analysis of action plan.
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WILLIAM BEE RIRIE
Critical Access Hospital
1500 Avenue H
Ely, Nevada 89301
775.289.3001
WILLIAM BEE RIRIE
Rural Health Clinic
6 Steptoe Circle
Ely, Nevada 89301
775.289.3612
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