Patient/Family Complaints And Grievances

A process for prompt resolution of patients concerns or grievances and a method for informing each patient whom to contact to file a grievance

Each patient, or the patient’s family and/or responsible guardian, will be fully informed of the patient’s rights and responsibilities prior to or at the time of admission to the hospital.

  • On admission the patient will be asked by admitting personnel to read and acknowledge that he/she has received a copy of the patient rights.
  • Copy of patient rights will include:
    • Patient Rights
    • Patient Responsibilities
    • Name of person(s) to contact in event of a grievance
    • Contact information for the person or persons named above and
    • Procedure for the submission of verbal or written grievance to the hospital

As described, a patient  complaint  will usually be handled by the staff present, including the individual hospital associate accepting the complaint, supervisor, or the department manager, either immediately or within a reasonably short time thereafter, as appropriate.

A patient grievance will be referred to the Director of Quality and Risk and will also be reported to the CNO. Grievances involving significant issues in the quality or timeliness of care will be reported and reviewed monthly through the Hospital’s Quality and Peer Review Committee/Quality Improvement process, and ultimately reported to the Board (i.e. not less than semi-annually as a sub-set of and during the course of reporting on Patient Satisfaction. (Patient grievances may also be reported to the Board more frequently as incorporated within the subject matter of the monthly report to the Board from the Quality and Peer Review Committee).

All verbal or written grievances will be acknowledged within 7 days by a phone or e-mail. If unable to reach the patient by phone or e-mail, a written notice of receipt will be made within 10 days.

An effort will be made on the part of the hospital to resolve all issues on as timely basis as possible in consideration of the nature of the grievance and its surrounding circumstances; however, at the outside, a written notice of the Hospital’s conclusions and its decision regarding the grievance will be sent to the patient within 30 days. If extenuating circumstances or outside review is necessary or key players in the issue are not immediately available, it may take longer. However, under the latter circumstances, the patient will be kept appraised of the situation at least once every 10 days.

The hospital’s written notice to the patient of its decision regarding the grievance will contain at minimum:

  • The name of the hospital contact person
  • The steps taken on behalf of the patient to investigate the grievance
  • The results of the grievance process, and
  • The date of completion

All hospital personnel will be properly oriented and directed to the complaint and grievance policy


Complaint:  A complaint is a concern which can be relatively easily solved or fixed with moderate or minimal effort by the staff present.

Grievance: According to the State’s interpretive guidelines, a “patient grievance” is defined as: “a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect.