Insert the Following Language Into the Material Given to Patients During the Admission

<THERE ARE ONLY A FEW REQUIRED FEATURES OF THIS COMMUNICATION: THE GENERAL OUTLINE OF THE GRIEVANCE PROCEDURE AND HOW TO CONTACT CMS (via DHS), THE QIO AND JCAHO. THE REST IS UP TO YOU.

<ATTACH RELEVANT PORTIONS OF THE ADMITTING INFORMATION PACKET TO THE PATIENT COMPLAINT AND GRIEVANCE PROCEDURE.

Your comfort, satisfaction and safety are very important to us and we hope to meet all of your needs without prompting. However, if you, your friends or your family have any concern, please let us know immediately: we will do our best to resolve it on the spot.

Who to contact:

Every nurse, every physician, everyone here at <NAME OF ORGANIZATION> is an advocate for your safety and satisfaction. Contact any one of our staff members at any time about your concerns. They will do their best to resolve the issue and, if they can’t, they will refer the matter to the <TITLE OF PERSON OR DEPARTMENT>, who will make sure there is an investigation and will work with you on a resolution. If you wish, you can contact this department directly at <NUMBER>. They will notify you once their investigation is complete and, when necessary, as their investigation progresses.

Here’s a list of other hospital leaders you may want to contact about your concern:. <INSERT DIRECTORY OF WHO YOU WANT THEM TO CONTACT.>

ü Our [Chief Executive Officer] may be reached at <NUMBER>

ü Our nursing department can be reached at <NUMBER>

ü Our dietary department number is <NUMBER>

ü Housekeeping’s direct line is <NUMBER>

ü Etc.

You also have the right to contact our regulators and accreditors directly.

ü Our hospital is licensed by <AGENCY NAME>, who also represents the federal agency responsible for our Medicare and Medicaid certification. You can contact <AGENCY NAME> at

ü If you are a Medicare or Medicaid beneficiary, you may also ask the regional Quality Improvement Organization (QIO) to review quality of care issues, coverage decisions and to appeal premature discharges. This organization’s QIO is <NAME>, which may be contacted at:

ü This hospital is also accredited by the Joint Commission on Accreditation of Healthcare Organizations, which encourages you to contact their Office of Quality Monitoring to by either calling 800/994-6610 or e-mailing “.”