Policy Description: Patient Satisfaction and Grievance


All Personnel


To provide information to the patients that they may express a written grievance to the Center or to the State Regulatory Agency regarding the quality of service received. To establish the process for reporting and analyzing patients’ satisfaction with care received at the Endoscopy Center.


The goal for the Endoscopy Center is to provide quality patient care. A process will be in place for patients to evaluate the Center, prompting analysis used to improve patient care and satisfaction and allowing patients to express grievances in a non-threatening environment.


Patient Grievance

Upon admission to the Center the patient will be given a copy of the Patient Rights and Responsibilities. The patient will also be given information on who to contact if they Wish to express a written grievance to UDH.

Written Grievance received by the Center will be recorded on the Patient Grievance Log along with identifying information and the nature of the grievance.

The Grievance will be documented on a Variance form and will be investigated according to policy and procedure. Any corrective action will be documented according to the Variance Policy and Procedure for the Center.

A written response will be forwarded to the patient to acknowledge the receipt of the grievance. A copy will be put with the Variance Form.

All patient grievances will be investigated and forwarded to the QI/RISK Committee. This information will be reported in the Risk Manager’s quarterly summary report.

Patient Satisfaction Surveys

All patients receive a questionnaire via email post discharge

  • The patients are instructed to fill out the survey and return it.
  • The QI Manager reviews all surveys returned
  • Statistics on how many surveys were returned, results and comments are gathered and reported to staff, QI/Risk Management Committee, Medical Executive Committee and Governing Body
  • All surveys with negative feedback are reviewed by the Administrator and acted on accordingly.

Telephone Interviews

  • When making the Post-op follow-up call, nursing staff will ask each patient and/or family member if they were satisfied with the care they received
  • All findings from the phone surveys will be reported and analyzed the same way the questionnaires are handled