Policies of the University of North Texas Health Science
Center
Chapter 14 – UNT
Health
14.305 Patient Complaint and Grievance Policy
Policy Statement.
UNT Health is committed to providing quality patient care and promoting patient/family
satisfaction.
UNT Health faculty and staff shall handle all patient/family complaints and grievances
consistently and in a timely manner.
UNT Health shall track and trend complaints and grievances and implement necessary
changes and process improvements under the direction of the Quality, Patient Safety and
Service Committee.
Application of Policy.
UNTHSC Faculty and Staff
Definitions.
Complaint is defined as a verbal expression of dissatisfaction by th
e patient/ family
regarding care or services provided by UNTHSC which can be resolved at the point at
which it occurs by the staff present. Most complaints will have simple solutions that can be
promptly addressed and are considered resolved when the patient/family is satisfied with
the action taken on their behalf.
Grievance is defined as a formal verbal or written expression of dissatisfaction with some
aspect of care or service that has not been resolved to the patient/family’s satisfaction at
the point of service. All verbal or written complaints of abuse, neglect, patient harm or the
risk of patient harm, a violation of the Patient Rights and Responsibilities are examples of
grievances. A verbal or written complaint sent to the Health Care Quality and Risk
Management department or any request from a family to treat a complaint like a
grievance will be considered grievance.
Procedures and Responsibilities.
Procedure / Duty
A. Complaints:
Responsible Party
1.
1. Any employee who receives a complaint from
a patient/family member shall immediately
attempt to resolve the complaint within that
employee’s role and authority.
Faculty and Staff
UNT SYSTEM POLICY TEMPLATE
2. If the complaint cannot be immediately
resolved, the employee shall escalate the
complaint through the appropriate chain of
command.
3. The supervisor or manager shall resolve the
complaint or take steps to continue the
resolution process with the knowledge and
agreement of the patient/family making the
complaint.
4. At any time during the complaint resolution
process, the department of Health Care
Quality and Risk Management may be
contacted for assistance, advice or support.
5. At any time during the complaint process, the
patient’s physician should be notified if
appropriate under the circumstances and
should be given the opportunity to assist in
resolving any complaints related to clinical
care.
6. Upon completion or resolution of the
complaint the manager/director of the
department shall communicate all findings to
the Health Care Quality and Risk Management
department on the Patient
Complaint/Grievance Form.
B. Grievances
1. If the complaint cannot be resolved or meets
the definition of a grievance, the manager/
director of the department where the
grievance occurred shall complete a Patient
Complaint/Grievance Form and notify the
Health Care Quality and Risk Management
department within 24 hours. The Health Care
Quality and Risk Management department
should be notified immediately of any sentinel
events, any actual or potential patient injury,
any allegation of abuse or neglect or any
potential for continued risk to patient safety.
Faculty and Management
Staff
Faculty and Staff
Faculty and Staff
Management Staff
Management Staff, Faculty
and Health Care Quality/Risk
Management
Management Staff
UNT SYSTEM POLICY TEMPLATE
2. The manager/director of the department
shall immediately notify the Director of
Regulatory Compliance and Privacy Officer of
any complaint concerning privacy/patient
confidentiality.
3. The Health Care Quality and Risk Management
department shall assist the department
manager/director in the investigation of the
grievance and shall determine if any peer
review committee should be involved in any
investigation. The investigation should address
any identified opportunities for improvement.
Any grievance involving a physician should be
discussed with the physician’s department
chair. The department chair shall be
responsible for any necessary intervention
with the physician including referral to peer
review if appropriate.
4. Upon conclusion of the investigation, the
Health Care Quality and Risk Management
department shall assist the department
manager/director or Department Chair in
completing a final written summary of the
investigation which shall be maintained by the
Health Care Quality and Risk Management
department.
5. The Health Care Quality and Risk Management
department shall provide a written response to
the patient/family making the grievance. If the
patient or authorized representative of the
patient is not the person making the grievance,
Protected Health Information of a patient that
may be included in the investigation summary
can only be released as allowed by law.
6. If the investigation of the grievance cannot be
completed within 10 days, the Health Care
Quality and Risk Management department
shall inform the person making the grievance
that the investigation is continuing and that a
written response will be forwarded
Management Staff
Management Staff,
Department Chairs and
Health Care Quality/Risk
Management
Management Staff,
Department Chairs and
Health Care Quality/Risk
Management
Health Care Quality/Risk
Management
Health Care Quality/Risk
Management, Department
Chairs and Management
Staff
UNT SYSTEM POLICY TEMPLATE
immediately upon completion of the
investigation. All grievances should be
identified, reviewed and responded to within
30 days.
7. All complaints and grievances shall be logged,
analyzed and tracked by the Health Care
Quality and Risk Management department.
Scheduled reports of complaints and
grievances shall be made to the Quality,
Patient Safety and Service Committee.
8. The Quality, Patient Safety and Service
Committee shall receive scheduled reports
from the Health Care Quality and Risk
Management department and shall be
responsible for reviewing and addressing
trends and for overseeing improvement
opportunities. The Committee shall make the
necessary reports to the UNT Health Board.
9. All complaints, grievances, investigations,
follow-up, tracking and trending reports
prepared by the Health Care Quality and Risk
Management department and the minutes and
proceedings of the Quality, Patient Safety and
Service Committee are considered committee
information and are privileged and
confidential. No information shall be released
without the permission of the Quality, Patient
Safety and Service Committee chairperson and
the Legal department.
Health Care Quality/Risk
Management
Quality, Patient Safety and
Service Committee
Quality, Patient Safety and
Service Committee, Health
Care Quality/Risk
Management and Legal
Department
References and Cross-references.
Patient Rights and Responsibilities Policy 14.304
Forms and Tools. All patient complaints or concerns are to be documented on the “Patient
Complaint/Grievance Form” located on the UNTHealth web site under Quality
Management Forms.
Approved: 7/8/2010
Effective: 7/8/2010
Revised: Drafted: 7/3/95, Approved: 8/30/01 Supersedes date: 7/3/95 & 7/24/98
