New Article on Streamlining the Patient Complaint and Grievance Capture and Resolution Process
Featured in November 2014 Issue of The Joint Commission Journal on Quality and Patient Safety

(Oak Brook, Ill., October 28, 2014) Joint Commission Resources today announced the release of the November 2014 issue of The Joint Commission Journal on Quality and Patient Safety. The issue features an article on how the Patient Representative Department (PRD) at Stanford Health Care, Stanford, California, created a streamlined patient complaint capture and resolution process to improve the record of patient complaints and grievances from multiple parts of the organization and manage them in a centralized database.

“Findings showed the number of complaints captured increased from 20 to 270 per month in @JC_Resources journal”  

In March 2008, after the PRD launched a data management system to track patient complaints and generate reports to leadership, it learned that it needed to modify and address its data input procedures. A re-evaluation of the overall work flow showed it to be complex with overlapping and redundant steps, as well as lacking standard processes and actions. As a result, it achieved the following:

  • Leadership engagement
  • Increased capture of complaints
  • Centralized dating and reporting of complaints
  • Improved average response times to patient grievances and complaints
  • Improved service recovery

The number of complaints captured increased from 20 to 270 per month, and patient concerns were linked to specific physicians 80 percent of the time—results that both represent “best-practice” status. Some 21 (68 percent) of 31 physicians who initially had a high number or severity of complaints have improved, 10 to such a degree that they no longer require messenger feedback visits to discuss patient complaints about their practice. Finally, with improved work flows, responses to patient complaints met a requirement of seven days or less.

The authors concluded that the availability of high quality data supports efforts to help physicians improve their interactions with patients. Stanford Health Care anticipates that patient expectations will continue to increase and require further improvements in care, patients’ experience, and timely, effective resolution of complaints and grievances. The PRD is continuing to use Lean management to further improve processes.

The remaining articles from the November 2014 issue are:

Performance Improvement
Implementing Best Evidence in Smoking Cessation Treatment for Hospitalized Veterans: Results from the VA-BEST Trial     
David A. Katz, M.D., M.Sc.; John E. Holman, M.A.; Skyler R. Johnson, M.S.; Stephen L. Hillis, Ph.D.; Susan L. Adams, RN, Ph.D.; Steven S. Fu, M.D., M.S.C.E.; Kathleen M. Grant, M.D.; Lynne M. Buchanan, RN, Ph.D.; Allan Prochazka, M.D., M.Sc.; Catherine T. Battaglia, Ph.D., RN; Marita G. Titler, Ph.D., RN; Anne M. Joseph, M.D., M.P.H.; Mark W. Vander Weg, Ph.D. 

A pre-post guideline implementation trial of a multimodal intervention was conducted at four U.S. Department of Veterans Affairs (VA) hospitals. Peridischarge interviews with 824 patients to assess receipt of the 5As (Ask, Advise, Assess, Assist, Arrange) indicated that subjects were significantly more likely to have received each of the 5As (except for “advise to quit”) from a nurse during the post-implementation period. However, unadjusted results showed no improvement in seven-day point prevalence abstinence at six-month follow-up (13.5 percent versus 13.9 percent). To promote long-term cessation, more intensive interventions are needed to ensure that motivated smokers receive pharmacotherapy and referral to outpatient cessation counseling, among other treatment. 

Clinical Processes
Barriers and Strategies for Effective Patient Rescue: A Qualitative Study of Outliers      
Elliot Wakeam, M.D.; Joseph A. Hyder, M.D., Ph.D.; Stanley W. Ashley M.D.; Joel S. Weissman, Ph.D.
Organizational factors influencing failure-to-rescue (FTR)—or death after postoperative complications—are poorly understood. Publicly reported data were used to identify 144 outlier hospitals. Interviews conducted with a purposive sample of four high-performing and three low-performing hospitals indicated six critical barriers to effective rescue and eight mitigating strategies. Results suggested that FTR is a complex process that is viewed, defined, and acted on differently across and within organizations. 

Lost In Translation? Addressing Barriers in the Application of Industrial Process Improvement Methodologies to Health Care       
Dean Gray, M.B.A.; Kimberly D. Johnson, RN, Ph.D., CEN; Brook Watts, M.D., M.S.

Features of the health care environment may conflict with best-practice norms necessary for process improvement and, as such, represent four barriers to its successful implementation. For each barrier, a best practice for successful process improvement and compensating strategies are provided.

Tool Tutorial
The Language Services Documentation Tool: Documenting How Patient Language Needs Were Met During Clinical Encounters      
Ranjani K. Paradise, Ph.D.; Yoon Susan Choi, Ph.D.; Linda Cundiff, RN, M.S.N.; Mursal Khaliif, M.A.; Laura Nevill, RN, M.S., ANP-BC; Robert P. Marlin, M.D., Ph.D., M.P.H.; Ffyona Patel, M.P.H.; Elisa Friedman, M.S.

Communication problems experienced by limited-English-proficient (LEP) patients during clinical encounters can adversely affect quality and safety of health care. At the Cambridge Health Alliance, Cambridge, Massachusetts, a single-question prompt, embedded in the electronic medical record was used to document the communication modalities used for each ambulatory care clinical encounter (face to face or telephone) with an LEP patient. 


Joint Commission Resources (JCR), a not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. JCR is an expert resource for health care organizations, providing consulting services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our Web site at


The Joint Commission


Creating a Patient Complaint Capture and Resolution Process to Incorporate Best Practices for Patient-Centered Representation

Letter to the Editor
Performance Improvement
Clinical Processes
Tool Tutorial


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Elizabeth Eaken Zhani
Media Relations Manager

Katie Looze
Media Relations Specialist



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