Effective Date: 7/86 Reviewed : 3/02, 3/05 Procedure Number: QMPP3

HealthNet

Community Health Centers

PROCEDURE:PATIENTGRIEVANCE

Section: ADMINISTRATIVE Responsibility: CHIEF OPERATIONS

PROCEDURES OFFICER

Effective Date: 7/86 Reviewed : 3/02, 3/05 Procedure Number: QMPP3

Related Policy: PRI 13

Purpose: To establish a formal mechanism and responsibility for receiving and

dealing with patient concerns.

Scope: All HealthNet Associates

Exceptions: None

Description:

We should encourage patients to resolve problems with HealthNet associates at the time they occur. If this is not possible and the patient is unsatisfied with the way a problem is resolved, the patient should be encouraged to reduce the complaint to writing. This way the concern can be handled in the most efficient and effective manner possible.

HealthNet associates encountering a patient with a complaint will offer them the Report of Patient Concerns/Comments form (see attached) and offer assistance if needed. Ample patient grievance forms should be available in each program area. The Clinic Manager/Program Director will be responsible for making sure these forms are located in a conspicuous and convenient place and situated next to a box where these forms may be deposited.

Once a grievance form is received, an investigation will be initiated within 72 hours by the Manager/Director. The appropriate Senior Manager will be notified as soon as possible and can provide assistance in follow-up with the patient involved if needed. A copy of all reports are to be forwarded to the Quality Management Specialist for tracking.

The HealthNet Chief Executive Officer shall be the body of final appeal for any patient grievance not satisfactorily resolved through HealthNet's procedures.

HEALTHNET COMMUNITY HEALTH CENTERS

REPORT OF PATIENT CONCERNS / COMMENTS

Date of Incident ______Time ______(AM / PM) Today’s Date ______

Patient’s Name ______Telephone ______

Address ______Zip code ______

Your Name ______

Staff Member(s) Involved ______

HealthNet site ______

DESCRIBE WHAT HAPPENED:

HOW WOULD YOU SUGGEST THAT WE SOLVE THIS PROBLEM?

Thank you very much for this information. Someone from HealthNet will contact you by mail or phone.

SEE BACK FOR STAFF RESOLUTION

STAFF RESOLUTION

Date Initiated ______Chart Number: ______

Staff Signature______Date______71979 CH-8019 (MAY 02)

CENTROS DE SALUD DE LA COMUNIDAD HEALTHNET

Reporte de quejas del paciente / comentarios

Fecha del incidente ______Hora ______(AM / PM) Fecha de Hoy ______

Nombre del Paciente ______Teléfono ______

Dirección ______Código Postal______

Su nombre (Sí es diferente al del paciente) ______

Miembro(s) del Personal Involucrados ______

Centro de HealthNet ______

Describa qué sucedió:

Que sugiere para que nosotros resoluamos este problema

Muchas gracias por ésta información. Alguién de HealthNet estará en contacto con usted por correo o teléfono.

Mire la decición del personal en la siguiente pagina 72035 CH-8021 (JULY 02)

STAFF RESOLUTION

Date Initiated ______Chart Number: ______

Staff Signature ______Date ______

72035 CH-8021 (JULY 02)