WILLIAM BEE RIRIE HOSPITAL & RURAL HEALTH CLINIC

Patient Concern Form

Systematic Concern Procedure

1. Patient(s)/customer(s) who have a concern may document said 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.

2. The documented Patient Problem/Concern Form(s) should be forwarded to Customer Service Manager: Patient/Visitor Concern Forms, if completed by an employee, should be forwarded to the Customer Service Manager within 24 hours. The Customer Service Manager is responsible, within 24 business hours, to provide the department manger(s) and/or physician(s) a copy of the Patient/Customer Service Concern Form.

3. The department manager(s) and/or physician(s) are, within 72 business hours, responsible for performing a root cause analysis and, if necessary, recommend system or process changes to the Customer Service Manager. As part of a root cause analysis, the manager will receive a written response from the employee(s) whom the complaint is directed.

Additionally, the department manager and or physician, if requested by the Customer Service Manager or CEO, is responsible to provide the Customer Service Representative a written response (draft) to the Customer Service Manager. Finally, if deemed necessary by the Customer Service Representative, the Customer Service Manager has authority to extend the 72-business hour root cause analysis requirement.

4. Manager(s) and/or physician(s) in all circumstances, from the Customer Service Representative, are provided identifying information about whom, when, where, and what to perform an appropriate root cause analysis. If adequate information is not available for the manager(s) and/or physician(s) to perform a root cause analysis, the Customer Service Representative will informally discuss the concern with the manager. The manager(s) and/or physician(s) is not required to provide a formal recommendation. The concern will not be included in the quality assurance evaluation and monitoring studies.

5.  The Customer Service Manager, after reviewing the department manager(s) and/or physician(s) system or process change recommendation(s), and, if applicable, policy and procedure changes, is responsible to review the changes with the CEO.  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 in accordance with Medical Staff By-Laws, by the Customer Service Manager.

6.  The Customer Service Manager, after obtaining CEO approval, will determine who performs written patient follow up.  Patient follow up is required unless the patient requests the follow up not be done or follow up was done as part of a patient survey and patient did not request follow up.

7.  The Customer Service Manager, as part of an ongoing quality assurance study, is responsible to evaluate and monitor patient concern information.  If available, the Customer Service Manager is resresponsible to benchmark data with other hospitals.  The Customer Service Quality Assurance Report will be reviewed with the CEO each month.  Additionallly, the customer Service Manager, after reviewing the report with the CEO, is responsible to review the customer Service Quality Assurance Report findings with appropriate department manager(s) and/or physician(s) on a monthly or next scheduled meeting basis.  Finally the customer Service Manager is responsible to present a monthly Customer Service Quality Assurance Report to the WBRH Medical Staff and WBRH Board.  

8.  The Customer Service Manager is responsible to maintain a Patient/Visitor Concern Form to include appropriate information regarding William Bee Ririe Hospital grievance and notification requirements.  The Customer Service Manager will assure Patient/Visitor concern Forms are available for patient access in the Hospital Admission's Office, Clinic Admission's Office and Hospital Billing Office.

9.  The written notification and answer to a concern, by the customer Service Manager, to a patient or customer, 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.

Grievance Committee

A Grievance Committee will be responsible for reviewing and referring complaints for investigation 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, and Quality Assurance-Performance Improvement / Risk Manager, and Customer Service Manager.  The Customer Service Manager will review complaints and investigations with the Grievance Committee, as necessary.

a.  The Customer Service Manager will obtain as much information as possible from the patient.  the Grievance Committee shall conduct an initial review within three days.

b.  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.

c.  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 Customer Service Manager, in coordination with the Quality Assurance-Performance Improvement 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 Bylaws 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 profesional review activities and thus shall be deemed to be "professional review bodies" as that term is defined by the Healtcare Quality Improvement Act of 1986.  The Customer Service Manager, in coordination with the Quality Assurance-Performance Improvement Manager will aintain, in secured files, the root cause analysis and action plan.