Complaint management: A comprehensive performance improvement process
I. POLICY
ALL complaints relative to the delivery of emergency care at Troubled Hospital, regardless of their origin, will be directed to and reviewed by the Emergency Care Management Team. All patient complaints are considered serious and will be investigated in a timely and appropriate manner.
All patient complaints are monitored as a Critical Indicator for the Department of Emergency Medicine and will be reported to Patient Care Management.
Centralizing the responsibility and accountability for the investigation, response to, and analysis of patient complaints is expected to optimize data collection and monitoring, illustrate trends and service patterns, and ultimately enhance patient satisfaction and emergency service delivery.
II. DEFINITION
As a matter of general policy, a complaint is considered to be: any negative comment generated by any person, telephone call, letter or patient survey, originating from a patient or family member, a hospital visitor, an employee or attending physician.
III. RESPONSIBILITY for participation in process
- Emergency Nursing Director
- Chair of Emergency Medicine
- Nurse Manager or Team Leaders
- Patient Care Management or Risk Management
- Hospital Administration
IV. PROCEDURE
1. Any complaint received from any hospital or other source relative to the delivery of emergency care at Troubled Hospital will be forwarded in writing or called immediately to the Emergency Nursing Director.
2. Every effort will be made to centralize complaints in this manner regarding the ED so that a timely investigation and response may be achieved by the management team.
3. The Emergency Nursing Director will review each complaint, refer to the Chair of Emergency Medicine as appropriate, and/or forward to appropriate divisional staff for investigation and response.
4. Complaint response will include a phone call to the complainant for eliciting circumstance and a written response following completion of the investigation. Any letter or recorded telephone complaint regardless of the source will receive a written response from the Emergency Nursing Director or Chair of Emergency Medicine; any letter directed to an administrative staff including the President or CEO will be drafted by the director(s) for the administrative member’s signature, and/or responded to directly by the Chair of Emergency Medicine.
5. A negative survey comment is considered a patient complaint and should be addressed. When the respondent has included their name and phone, every attempt should be made to investigate the circumstance and address the issues as if it were a formal complaint; however, survey complaints will be classified and tallied separate from formal complaints since retrospective patient surveys are not always reflective of current circumstance.
6. Investigation and response will be requested/completed on "Complaint Management" form available at select locations, i.e. administrative offices, nursing supervisors and the nursing director’s office. If the complaint is received in the director’s office in a less formal format, the information will be transcribed in writing to the "Complaint Management" form for due process.
7. The "Complaint Management" form may be generated by any individual i.e. administrative secretary, ED staff member, telephone transcriber, or Guest/Public Relations.
8. The designated form will be used for documentation, investigation, and response by the medical or nursing directors, and the original will be forwarded quarterly to Patient Care Management for tally and central filing as a completed file. Original letters or documentation should be parcel to this central file.
9. Every effort will be made to provide a timely response to all patient complaints regardless of their severity or source. The ED will track and summarize all complaints according to specific issues identified on the complaint management form and report these, their address, and resolution to Patient Care Management and the Emergency Services Committee.
10. The numbers and types of complaints received regarding emergency care will be tallied by Patient Care Management staff and reported monthly as a Critical Indicator and quarterly in a summary performance improvement report for the Emergency Services Committee.
11. Alleged adverse events, serious complaints, and notable trends will be a priority agenda item at monthly multi-disciplinary departmental meetings.
12. All complaints but especially patient complaints are considered serious and are a Critical Indicator for the ED Performance Improvement process.
13. Serious complaints or any whose allegations include misdiagnosis or inappropriate medical management will be immediately referred to the Chair of Emergency Medicine for review; any complaint that meets the criteria for a serious or sentinel event should be forwarded immediately to Patient Care Management.
Source: Michelle Regan Donovan, RN, BSN, Millennium Strategies, Charlottesville, VA.
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