Patient and Visitor Concerns

Patient(s)/Visitor(s) who have a concern may document their concern on the Patient/Visitor Concern Form.   Additionally, an employee or other interested party may complete the Patient/Visitor Concern Form on the patients’ behalf.

All Patient/Visitor Concern Form(s) should be forwarded to the COO and/or CEO.  Patient/Visitor Concern Form(s), if completed by an employee, should be forwarded to the COO and/or CEO within 24 hours.  The COO and/or CEO is responsible, within 3 business days, to provide the department manager(s) a copy of the Patient/Visitor Concern Form.

The department manager(s) will review the concerns and assist in forming a response within a reasonable time frame.  If necessary, the department manager(s) will recommend system or process changes to the COO and/or CEO.  As part of a root cause analysis, the department manager will receive a written response from the employee(s) to whom the complaint is directed.  Additionally, the department manager and/or physician, if requested, is responsible for providing a written response (draft) to the COO and/or CEO.

Manager(s) and/or physician(s) in all circumstances will be provided identifying information about whom, when, where, and what, from the COO and/or CEO to perform an appropriate root cause analysis.  The exception to this can be made if additional confidentiality is requested by the person submitting the Patient Concern Form, at which time the COO and/or CEO will use a number in place of a name.  A copy of all numbers associated with patient names will be kept by the CEO.    If adequate information is not available for the manager(s) and/or physician(s) to perform a root cause analysis, the COO and/or CEO will informally discuss the concern with the manager(s).  The concern will not be included in the quality assurance evaluation and monitoring studies.

The COO and/or CEO after reviewing the department manager(s) and/or physician(s) system or process change recommendations(s) and if applicable, policy and procedures changes, is responsible to review the changes.  Additionally, the Chief of Staff or physician designated by the Medical Staff will review concerns regarding a physician.  The Vice-Chief of Staff or designated physician, Medical Staff Peer Review, or other designated physician by Medical Staff 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.

The COO and/or CEO will perform written patient follow-up.  A Patient follow-up is required unless the patient requests the follow-up not be done or the follow-up was done as part of a patient survey and the patient did not request follow-up.  If follow-up needs to be extended for some reason, the patient will be contacted to be given an update as to the current status of the Patient’s Concern and an expected time frame for completion.

The COO and/or CEO as part of an ongoing quality assurance study, is responsible for evaluating and monitoring patient concern information.  If available, the COO and/or CEO are responsible for benchmarking data with other hospitals.

The COO and/or CEO 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 ensure Patient/Visitor Concern forms are available for patient access in their departments.

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

All Patient/Visitor Concerns must go through the Concern process before the Grievance Process, unless there may be legal ramifications associated with the concern.

Patients/Visitors who have been through the Concern Procedure and would like further review of their concern may document their 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.

All Patient Grievance Form(s) should be forwarded to the COO and/or CEO within 1 business day of receipt. The COO and/or CEO is responsible, within 3 business days of receipt, to inform department managers of a grievance that has been filed in relation to their department.

The department manager(s) are responsible for providing the documentation supporting the completed Patient/Visitor Grievance Form to the COO and/or CEO as soon as possible if the information has not already been provided. If additional investigation is warranted, the COO and/or CEO may ask the department manager(s) to provide information for the investigation.

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 COO and/or CEO. The exception to this can be made if additional confidentiality is requested by the person submitting the Patient Grievance Form, at which time the COO and/or CEO will use a number in place of a name. A copy of all numbers and patient names will be kept by the CEO.

The  COO and/or CEO, after reviewing the department manager(s) response to the Patient Grievance Form, is responsible for reviewing the grievance. 

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.

The COO and/or CEO will perform written patient follow-up 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.

The COO and/or CEO, as part of an ongoing quality assurance study, is responsible for evaluating and monitoring patient grievance information. If available, the COO and/or CEO are responsible for benchmarking data with other hospitals.

The written notification and answer to a concern, by the COO and/or CEO to a patient, 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.

The COO and/or CEO will obtain as much information as possible from the patient and will provide this information to all committee members for review.

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.

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.