Patient Complaints/Grievences

Patient Complaints Grievances

PURPOSE:  To define a process for responding to patient care complaints, concerns or grievances in a consistent and timely manner.

POLICY:  The hospital acknowledges the rights of patients to make comments, express dissatisfaction, file complaints or grievances, and to expect the hospital to undertake appropriate actions in response. 

Patients and families are informed of their ability to voice a complaint through information provided at registration or admission. Information is also available on the website.

Any patient or family member who makes a significant complaint will receive a written or verbal response from the department manager involved or administration.

Verbal complaints, which are expressed by patients during their stay in the facility, will be directed first to the appropriate department and then, if unresolved, to the administrator. Every effort will be made to resolve the complaint while the patient is still in the facility. Responses to significant complaints will be given to the patient or family either verbally or in writing, whichever will best solve the problem.

Any other staff member receiving a complaint will complete a Patient Complaint form in Clarity reporting system. Complaints will be forwarded to the appropriate supervisor for follow-up.  If the complaint, however, is related to HIPAA, the completed complaint form will be forwarded to the compliance officer. Data will be compiled, analyzed for trends, and reported in the quality assessment and improvement data for the department or for administration, as appropriate, and communicated to the Board of Directors.

Complaint:  A written or verbal concern or objection from a patient or the patient’s designated representative regarding the quality or appropriateness of patient care that can be effectively addressed and resolved by informal means.

Grievance:  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 through informal means, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs) or a Medicare beneficiary billing complaint related to rights and limitations.

Any formal written complaint is always considered a grievance. Emails and faxes are considered formal written documents.

Information on patient satisfaction surveys is considered a grievance if the patient writes or attaches a written complaint on the survey and requests a resolution. 

Each employee is empowered to address patient complaints at the point of conflict.

  1. Complaints
  2. Complaints relating to allegations of substandard care, harm or actual injury require additional interventions to resolve the complaint quickly and effectively.  Most patient complaints can be managed efficiently by the leaders of the hospital when interventions are undertaken in a timely manner.  Coordination and consultation with supervisors, physicians or the Chief Executive Officer may be necessary. 

Employees unable to resolve a concern or who become aware of a complaint alleging harm or injury to a patient should respond immediately by notifying their manager.

Employee will:

  1. Validate the complaint by communicating directly with the patient. Ensure that the complaint is clearly understood and that all appropriate actions have been taken to attempt to resolve the complaint. The customer service recovery program may be utilized if appropriate.
  2. If there is an allegation of actual or potential harm to the patient, take proper steps to ensure the patient’s safety. Communicate and coordinate with the attending physician and Chief Operating Officer or Unit Supervisor.
  3. Focus on the patient’s complaint. Remain empathetic and concerned, but refrain from acknowledging responsibility or fault.
  4. Submit a Clarity incident report (complaint). Immediate or earlier notification should be made when necessary in the judgment of the employer.
  5. The policies pertaining to incident reporting and sentinel event reporting should be followed when they apply.


The COO will:

  1. Communicate with the patient directly, if possible.
  2. Assess the situation to determine if appropriate action was taken.
  3. Assess the patient’s response and determine if the action taken has met the patient’s expectations.
    • If the patient is satisfied, close the complaint.
    • If the patient remains dissatisfied, the complaint becomes a grievance.


Cumberland Memorial Hospital Grievance Process provides patients with a formal process for addressing complaints relating to care and services in the hospital.  All patients have a right to file a grievance, obtain information on how to file a grievance and expect a timely, written response that includes any decisions the hospital makes regarding the grievance, the name of a contact person, steps taken to investigate the grievance, the results of the grievance process and the date of completion. The following paragraphs describe the grievance organization and process.

  1. Notification
  • All patients are notified of their right to file a grievance and the procedures to follow should they desire to do so.  Patient information is provided upon registration and is used for this notification.  (Attachment 3)
  • Any grievance involving situations that may endanger the patient such as abuse or neglect shall be reviewed immediately according to the Abuse, Neglect and Misappropriation policy and procedure.

2.  Submission of Grievances

  • Patients filing a grievance may do so following the guidelines found in the information provided on admission.

3. Timeliness of Completion

  • Grievances filed by patients will be responded to within 7 days from the date received and completed within 30 (thirty) days of receipt.  Grievances are considered completed when an approved response has been mailed by registered mail to the patient.


The CMH Grievance process is approved by the Governing Board who has delegated responsibility for reviewing and resolving grievances to the hospital CEO.

  1. The Chief Executive Officer will:
    1. Log receipt of grievance correspondence to include the date received, sender’s name, address, telephone number, nature of grievance, resolution and date of response letter. (Attachment 4).
    2. Review the grievance to understand the nature of the grievance and decide how and by whom the grievance shall be investigated.
    3. Appoint an appropriate leader to investigate the grievance.
    4. Establish timelines for completion of the investigation and preparation of the written response to the patient.
    5. Review the results of the investigation to ensure each point or issue identified in the grievance has been appropriately addressed.  Make decisions relating to the grievance and prepare or direct the preparation of the written response to the patient.  Review the response to ensure it is in compliance with this policy and applicable laws, rules and regulatory guidelines.  The written response shall address the following elements: the decision of the hospital, the steps taken to investigate the grievance, a contact person and the result of the grievance and date of the letter.
    6. Mail and archive copies of all responses.
    7. Monitor informal complaints and formal grievances for trends through review by Compliance Committee.
    8. Provide statistics and summary reports annually and/or as requested to the Governing Board.
  2. Investigating Leader will:
    1. Thoroughly and objectively investigate every issue raised by the patient in his/her grievance.
    2. Collect factual evidence through interviews with staff, review of the medical record and review of pertinent policies and procedures.
    3. Document the results of the investigation and prepare a draft response for review by the Chief Executive Officer within the prescribed time frame.

Governmental Agency Complaints

Complaints received from governmental agencies require a response in a prescribed format and must meet prescribed timelines. Penalties, including fines and on-site investigations may result if procedures are not followed.  Employees receiving written complaints or requests for information from governmental agencies should contact the Chief Executive Officer and follow the process outlined below:


  1. Respond rapidly. The situation will not “go away” if you ignore it.  Issues that are quickly addressed do not routinely turn into major complaints.
  2. Introduce yourself and explain your role at the facility.  Offer your help in resolving the situation.  This is part of everyone’s role as a patient advocate.
  3. Listen carefully and gather information. Take notes. Remember to document exact statements that are important to the issue.  Consider your body language and tone of voice.
  4. Do not allow yourself to be drawn into an argument. Do not take statements personally. In most cases, the patient is angry or concerned with an issue, not with you as an individual.  If you feel that you need assistance, call your supervisor.
  5. Do not agree or disagree with statements presented as facts. This can escalate emotions and feed dissatisfaction. Actions will be taken after all the facts are considered.
  6. Ask non-threatening, non-defensive questions.  Attempt to clarify the facts of the situation. Ask what you can do to help today and resolve the problem.
  7. Do not make promises that you cannot keep.  Remember, you have only one side of an issue.  Your job is to gather information, not to place blame or accept responsibility.
  8. Sincerely apologize for failing to meet the patient’s expectations and thank him/her for taking the time to let you know about the situation.
  9. If this is a concern you cannot personally resolve, forward the information to individuals who can investigate and respond. This may include your manager.
  10. Let the patient know when, and by whom, they can expect a response.


(This can be done in conjunction with the “Guidance on Checking and Reviewing Written Responses”)

Issues to bear in mind:

  • There is no such thing as a standard letter and each one should be personalized
  • No two complaints are the same and require different responses
  • Choose words appropriate to the complaint and the complainant
  • Try to put yourself in the complainant’s shoes
  • Be simplistic, not complicated
  • Be courteous, clear, concise and complete
  • The greatest impact is the tone of the letter
  • Respond to ALL points raised
  • Ensure you use good English/grammar with no inappropriate jargon
  • Be honest and open
  • Avoid judgments unless professional and relevant
  • Include only relevant clinical/technical details

Steps to Follow

  • Read the complaint letter thoroughly
  • Check that you have fully investigated and obtained all necessary statements
  • Separate out, all the issues to be addressed
  • Structure your thoughts before putting pen to paper
  • Ensure all points are answered
  • Read your response through once completed or ask a colleague to read it

Structure of Letter

There is no perfect letter, but the following may be helpful.  See attached as an example copy of a complaint letter and response, incorporating these aspects:

  • Name and Address – make sure you are addressing the correct person – is it the patient or the complainant?
  • Opening Paragraph – outline the issue to be addressed and thank them for bringing it to our attention.
  • Early Apology – it helps to make an early apology and if a mistake has been made, acknowledge this.
  • Body of Response – the body of the response needs to give the results of the investigation that has been carried out in answer to each of the issues raised by the complainant.  This should be done either sequentially as raised within the actual complainant letter or, if easier, in a chronological format.
  • Action Plan – you need to make it clear what action has already been taken or is to be taken and discuss follow-up intentions.  Ideally a time-scale should be attached to this.  If it is not possible to do what has been asked, this needs to be explained, giving reasons why.
  • Learning Points – if appropriate, explain how the organization has learnt from the complaint being made and thank the complainant for helping you to improve the service for others.
  • Closing Paragraph – give further apology if appropriate. Have a ‘closure’ sentence, but provide offer of further assistance should this be necessary.


Those responsible for composing or reviewing the final response letter to a complainant should go through the following checklist before it is sent to the complainant.

Check for factual accuracy:

  • Is the letter addressed to the correct person?
  • Is the name and address correct?
  • Is the letter dated?
  • Who is the letter coming from?
  • Are all those who have been involved in supplying information as part of the investigation, including Clinicians, happy/agreeable that the facts in the final letter are accurate?

Spelling and Grammar:

  • Does the letter read well – is it good English?
  • Are there any typographical or grammatical errors?
  • Is there any jargon used – has it been explained or is there a better way of explaining this?
  • If abbreviations are used, have they been explained in full on their first reference?
  • Are facts and figures used and do they need to be checked?

Check the tone of the letter:

  • If the response is late, has this fact been acknowledged with a reason explained and an apology given, at the beginning of the letter?
  • Have we acknowledged the concerns raised by the complainant?
  • Is the letter defensive?
  • Is the letter patronizing?
  • Have we tried to baffle the complainant with lots of unnecessary technical/clinical jargon?
  • Is any necessary technical information explained?
  • Does the letter appear clinical and cold?
  • Have we simply quoted information from the medical records?
  • Have we given a full history instead of focusing on the issue raised?
  • Have we been honest and open?
  • Have we apologized where appropriate, without sounding insincere – should not be left until the end of the letter?
  • Where appropriate, have we thanked the complainant for their feedback and explained what actions/changes will occur as a result?
  • Have we provided a contact name and number if the complainant has further concerns?

Have all the issues raised by the complainant been answered?

  • Has each issue raised in the complainant’s letter been cross-checked with answers/explanations in the response? If any item has been missed out/overlooked, the complainant is very likely to come back!
  • Have these been addressed in a logical fashion?
  • Has the real point of the complaint been missed? Not always easy to grasp from reading the complainant’s letter.

Risk Management Issues

  • Does the complaint raise a clinical treatment, care, or possible legal issue?
  • If so, it may be helpful to discuss this with the department leaders or facility liability insurer.

Clinic Governance Issues

  • Are there lessons to be learned from the complaint?
  • Has the learning from the complaint been shared within the organization?
  • Have all promised actions been logged/documented, with a system in place to ensure they will be undertaken?
  • Once promised actions have been carried out, is there auditable, documented evidence to demonstrate such actions have actually been undertaken?

Remember:  The first couple of paragraphs and the final paragraph have the greatest impact.  Try to put yourself in the complainant’s shoes. Would you be pleased with the letter if it dropped onto your doormat?




  • We want to do our very best to make sure you receive the best care and services we can provide.  All of us are dedicated to meeting your needs, keeping you safe and making your stay with us as comfortable as possible.
  • Should we fail to meet your needs, or you are dissatisfied with any aspect of your care, the Cumberland Memorial Hospital has adopted procedures to help you let us know about your concerns and take action to help you resolve them. This brochure is designed to help you understand the options available to you in resolving concerns you may have about your care and the services we provide.
  • Certain Federal and State laws also give you specific rights with regard to filing grievances and complaints regarding care and services.  This brochure explains those rights and gives you the information you need to file an official grievance or complaint
  • After reading this brochure, if you have questions or need further information, contact the manager of the department or the Chief Executive Officer for assistance.

What should I do if I have a concern or am dissatisfied with something?

The most important thing you can do is let us know about it right away.  Talk to your nurse or anyone else involved in your care.  They will do their best to help you resolve your concern or find someone who can assist you.  Most of the time we can take care of things right away but, we can’t help you if we don’t know there is a problem.

I already tried that and it didn’t work.  Now what?

If you feel your concerns have not been adequately addressed by those providing your care ask to speak with a representative from administration. Ask for a visit by the manager of the department or Chief Executive Officer. Let them know exactly what the problem is and how they can help.

What if I am still not satisfied and want something done?

You may file a formal grievance. Upon filing your grievance, an investigation will be completed and you will receive a written response within 30 (thirty) days that include:

  • The decision of the hospital
  • The steps the hospital has taken to investigate your grievance
  • The results of the grievance
  • The date of completion
  • The name of a contact person at the hospital

Steps to follow in filing a formal grievance:

  1. Submit your grievance in writing to the Chief Executive Officer of the hospital.
  2. State that you are filing a grievance in accordance with the hospital’s grievance process.
  3. Include date of service, patient name, procedure and complete nature of the grievance, listing previous actions taken in efforts to resolve the grievance and expected outcome.

Wisconsin law gives patients the right to file a complaint related to care and services of the hospital with the Wisconsin Department of Health & Family Services.

Department of Health Services

Division of Quality Assurance

Bureau of Health Services

PO Box 2969

Madison, WI 53701-2969

Phone: 608-266-8481 or 1-800-642-6552


Complaints about physicians, as well as other licensees and registrants of the Wisconsin Department of Health Services may be reported for investigation at the following address:

State of Wisconsin                                                                           Kepro

Department of Safety & Professional Services                           5700 Lombardo Center Drive

Division of Legal Services & Compliance                                   Suite 100; Seven Hills, OH 44131

PO Box 8935                                                                                     1-800-362-2320

Madison WI 53708-8935                                                    


Phone: 608-266-7482

Fax: 608-266-2264                                                                     The Joint Commission

E-mail:                                                        Office of Quality Monitoring

Website:                                                    One Renaissance Blvd

                                                                                                         Oakbrook Terrace, IL 60181




                                                                                                           Fax: 630-792-5636