Campus Health: Suggestions/Concerns Policy

This policy establishes the right of patients, family members, and staff to submit suggestions and concerns about Campus Health services, patient care, and safety, and ensures those submissions are reviewed and addressed appropriately. It also outlines the procedure for collecting, documenting, routing, and responding to suggestions and concerns, including external escalation options such as the Joint Commission and CMS.

Unit Policy

Title

Campus Health: Suggestions/Concerns

RI-19

Introduction

Purpose

This policy establishes the right of patients, family members, and staff to submit suggestions and concerns about Campus Health services, patient care, and safety, and ensures those submissions are reviewed and addressed appropriately. It also outlines the procedure for collecting, documenting, routing, and responding to suggestions and concerns, including external escalation options such as the Joint Commission and CMS.

Scope

This policy applies to patients, family members, and Campus Health staff — both in terms of their right to submit suggestions and concerns, and the responsibilities of Campus Health personnel in receiving, routing, and responding to them.

Policy

Patients, family members, and staff have the right, and are encouraged, to offer suggestions and/or concerns regarding Campus Health, patient care, and safety. They also have the right to have these issues reviewed, addressed, or resolved when appropriate. "Suggestions" are defined as statements about patient care experiences or Campus Health processes that have been satisfactory. "Concerns" are defined as statements about patient care or processes and/or experiences that have not been satisfactory. In clinical and ancillary support areas, every effort should be made to address and/or resolve suggestions/concerns as appropriate when they are presented. In the event the individual has any suggestions/concerns about patient care and safety within Campus Health that the organization has not addressed, the individual is encouraged by Campus Health staff to contact the Joint Commission.

The patient, family member, or staff member may contact the Joint Commission's Office of Quality Monitoring to report any concerns by calling 1-800-994-6610 or submitting a report online through the Joint Commission's website.

The patient, family member, or staff member may also contact the Centers for Medicare and Medicaid Services (CMS) Central Office, Division of Laboratory Services (CLIA), at 410-786-3531 or 1-877-267-2323 (toll-free), extension 63531, for concerns about laboratory operations. Please see the CMS Brochure on Laboratory Complaints for more information.

The patient, a family member, or a staff member may contact the Campus Health Privacy Officer (Attn: Privacy/Security Officer, 919-966-6557) or the University Privacy Officer (Attn: privacy@unc.edu) regarding concerns about patient privacy. They may also send a written complaint to the United States Secretary of Health and Human Services (HHS). Contact information can be found on the HHS Office of Civil Rights website. If a patient files a complaint, no action will be taken against the patient, nor will the patient's treatment be changed in any way.

The following procedure should be implemented to accurately collect, document, and report pertinent information.

Procedure

1. The Campus Health staff member who has initial contact with the patient should initiate a Patient Suggestion/Concern form. An individual serving in a supervisory capacity is expected to handle the situation in accordance with accepted management and/or conflict resolution principles. The completed Patient Suggestion/Concern form is forwarded to the Performance Improvement Coordinator.
2. Campus Health patients, family members, and/or staff are informed of their right to present a suggestion/concern and the means of doing so. This information is disseminated through the "Rights and Responsibilities" flyers posted throughout the building and on the Campus Health website.
3. Patients are encouraged to communicate directly with the health care provider or other staff member most directly involved in the matter. Other options for registering a suggestion/concern are as follows:
   1. Posting an inquiry via the Campus Health website, which is then forwarded to the appropriate supervisor to address. Feedback may also be submitted using the online form submission on the Campus Health website.
   2. Patients, family members, and/or staff may voice suggestions/concerns in the Campus Health Administration. Such matters will be handled initially by the appropriate Campus Health personnel, depending on the nature of the concern.
   3. Patients, family members, and/or staff may voice suggestions/concerns to any member of the Campus Health Advisory Board.
4. Suggestions/concerns related to patient care are referred to the Director of Nursing and/or Medical Director, and if applicable, are forwarded to the Medical Peer Review chair for review.
5. Suggestions/concerns related to financial or other administrative matters are referred to the Director of Business and Support Services.
6. Suggestions/concerns related to Laboratory Services are referred to the Director of Pharmacy and Professional Services.
7. Suggestions/concerns related to Radiology or Pharmacy Services are referred to the Director of Pharmacy and Professional Services.
8. Suggestions/concerns related to Counseling and Psychological Services are referred to the Director of Counseling and Psychological Services.
9. Suggestions/concerns related to Sports Medicine are referred to the Director of Sports Medicine.
10. Suggestions/concerns related to patient privacy are referred to the Privacy Officer.
11. Each signed complaint will receive a written or telephone response within 48-72 hours from a Campus Health administrative official, including appropriate corrective action taken and the modification of policies and services as deemed necessary.
11. Each complaint regarding patient privacy and its disposition will be documented and maintained by the Privacy Officer, and a copy will also be forwarded to the University Privacy Officer. Employee sanctions, if necessary, will be handled in accordance with the applicable Campus Health or UNC-Chapel Hill Human Resources policy.
12. Positive and negative comments will be shared confidentially with any employee identified by a patient, family member, and/or staff.
13. Presentation of a suggestion/concern in no way shall compromise the patient's or employees' future access to care or his/her stated rights or employment status. No retaliatory action will be taken against patients, family members, and/or staff who present their suggestions or concerns.

Attachment

• Attachment 1: Suggestion/Concern form

Contact Information

Primary Contact

Name: Melody Gibson, Health Information Manager

Telephone: 919-966-6557

Email: mgibson@email.unc.edu

Publication Details

Issuing Officer: Ken Pittman, Executive Director of Campus Health

Effective Date: May 1984

Last Review Date: May 2024

Next Review Date: May 2027