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Grievance Policy and Procedure for Patients Receiving Care on the Psychiatric Unit or in an AODA or Behavioral Health Clinic (2.4.5)

Grievance Policy and Procedure for Patients Receiving Care on the Psychiatric Unit or in an AODA or Behavioral Health Clinic (2.4.5) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Behavioral Health

2.4.5


UW HEALTH CLINICAL POLICY 1
Policy Title: Grievance Policy and Procedure for Patients Receiving Care on the
Psychiatric Unit or in an AODA or Behavioral Health Clinic
Policy Number: 2.4.5
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: November 1, 2016

I. PURPOSE

To define the process to hear and resolve grievances filed by patients receiving treatment at behavioral
health locations when they believe that their rights have been violated. Note: This policy only applies to
grievances on the Inpatient Psychiatric Unit, or in a Substance Abuse (alcohol and other drugs of abuse
(AODA)), or other Behavioral Health Specialty Clinics. For all other patient complaints or grievances, please
refer to UWHC clinical policy #4.46, Responding to Patient/Family Complaints and Grievances.

II. DEFINITIONS

A. Client Rights Specialist (CRS): A person designated to facilitate informal resolution of concerns and to
conduct program level reviews of grievances and make proposed factual findings, determinations of merit,
and recommendations for resolution, which are provided, to the program managers and the client. UW
Health’s designated CRS are located in the Patient Relations Department. They are available to patients by
calling (608) 263-8009.
B. Informal Grievance: A complaint, disagreement or dispute in which a patient (or a representative on behalf
of the patient) may have with the program or program staff which the patient (or representative on behalf of
the patient) chooses to resolve through an informal resolution process (see section IV below).
C. Formal Grievance: A statement by a patient or representative of the patient (referred to in this policy as a
grievant) that an action or inaction by the program or its staff has abridged the rights guaranteed to a patient
under Wisconsin Statutes section 51.61 or Wisconsin Administrative Code Chapter DHS 94. A grievance is
addressed by the program’s formal grievance resolution process (see section V below). Note: a patient or
other grievant may agree to an informal resolution of his or her concern, thereby avoiding the formal
grievance resolution process.
D. Program Manager: The individual in charge of the program who has the specific authority to approve and
implement decisions made through the grievance resolution process. UW Health’s designated Program
Manager for the Inpatient Psychiatric Unit is the Nurse Manager; the designated Program Manager for other
sites is the clinic manager.
E. Grievant: The patient or someone who is filing a grievance on the patient’s behalf.

III. POLICY ELEMENTS

A. Patients receiving mental health or substance abuse services from the Inpatient Psychiatric Unit or a
Substance Abuse (alcohol or other drugs of abuse (AODA) or other Behavioral Health Specialty Clinics will
be given a copy of their patient rights, as well as written materials explaining the grievance process. Patient
rights should be read to the patient in person, and patients should be informed of how to file grievances.
B. The grievance procedure is to assure patients that their rights will be protected and enforced by all UW
Health staff. There is no cost to patients when filing grievances. Retaliation will not occur to patients or staff
members as a result of expressing concerns or filing grievances.
C. If at any time the CRS determines that a patient or group of patients is at risk of harm and the program has
not yet acted to eliminate the risk, the CRS will immediately inform the program manager, the county
department operating or contracting for operation of the program (if any) and the state agency responsible
for investigating grievances.
D. Where a parent of a minor or a guardian’s consent is required for treatment, that individual shall generally be
involved in the grievance resolution process and receive copies of relevant documentation.

IV. PROCEDURE FOR INFORMAL GRIEVANCE RESOLUTION

A. All staff are encouraged to help patients to resolve informal grievances at the unit level. The CRS is
available upon request to facilitate resolution of informal grievances. Staff should listen to the nature of the
informal grievance, discuss the matter with staff and other individuals as needed, and work toward a
mutually acceptable resolution.
B. If the informal grievance is expressed to the CRS and the program manager is not involved, the CRS will



UW HEALTH CLINICAL POLICY 2
Policy Title: Grievance Policy and Procedure for Patients Receiving Care on the Psychiatric Unit or in an AODA or
Mental Health Clinic
Policy Number: 2.4.5

provide the program manager and the grievant (and the patient, if other than the grievant) with a brief
summary of the informal grievance and seek resolution.
C. If a grievance cannot be resolved informally, staff will inform the grievant of the formal grievance process.
D. The informal grievance process is optional, is not a prerequisite for pursuing a formal grievance, and may be
used as an adjunct during the formal grievance resolution process. Grievants may file a formal grievance at
any time. If the grievant expresses a wish to file a formal grievance, staff must contact the CRS, and the
grievance will follow the process outlined in section V below.

V. PROCEDURE FOR FORMAL GRIEVANCE RESOLUTION

A. If the informal grievance process does not resolve a grievance or if the grievant (and the patient, if other
than the grievant) chooses to file a formal grievance immediately, the process in this section V will be
followed.
B. A formal grievance may be presented to the program manager, CRS, or any staff person in writing, orally, or
by an alternative method of communication ordinarily used by the grievant. A grievance must be filed within
45 days of: the occurrence of the event or circumstance complained of; the time when the event or
circumstance was actually, or should reasonably have been, discovered; or the grievant gaining or regaining
the ability to report the matter, whichever is latest. The 45-day time limit may be extended for good cause by
the program manager.
C. If the grievance was presented orally or through an alternative method, the CRS shall assist the grievant in
putting it into writing for use in the ongoing process. A copy of the written grievance shall then be given to
the grievant (and the patient, if other than the grievant).
D. All grievances are confidential and the name or other identifying information of the patient or other grievant
shall not be released to any person whose knowledge of the information is not necessary for the resolution
of the grievance.
E. There is no limit to the number of grievances that any person may submit. However, when a grievant has
multiple pending grievances, the CRS may establish an expanded timetable with specific priorities for
investigation and resolution of the grievances. The CRS shall notify the grievant (and the patient, if other
than the grievant) and the program manager of the timetable and priorities within ten days after beginning
the inquiry.
F. After a grievance is filed, the following timeline must be followed:
i. Non-Emergency Situations
a. Program staff will present grievances to the program manager as soon as possible but not
later than the end of the staff person’s shift. The program manager will contact Patient
Relations so that a CRS can be assigned within three business days.
b. The CRS will meet with the grievant (and the patient, if other than the grievant),
investigate the matter and prepare a written report that explains why the grievance is
founded or unfounded and the basis for that determination. The report will also include a
description of relevant facts agreed upon by the parties or gathered during the inquiry and
the application of the appropriate laws and rules to those facts. If the grievance is
founded, the CRS’s report must contain recommendations for resolving the matter. If the
grievance is unfounded but contains program quality or improvement, the CRS report may
include informal suggestions for improving the situation. The report must be completed
within 30 days from the date the grievance was initially presented and must be provided to
the program manager, the grievant (and the patient, if other than the grievant), all relevant
staff.
c. Care should be taken not to disclose the patient’s protected health information to a
grievant (when other than the patient) without patient authorization unless disclosure is
otherwise permitted under UW Health’s privacy policies. The CRS shall purge from the
report the names or other patient identifiers of any patient involved in the grievance other
than the patient directly involved, except when providing the report to staff who are directly
involved, the program manager, and other staff with a need to know that information.
d. If there is disagreement over the CRS report, the CRS may confer with the grievant (and
the patient, if other than the grievant), the program manager, and others as appropriate to
attempt establishment of a mutually acceptable plan for resolving a grievance.
e. After receiving the CRS’s report, and provided the discussions in section V.F.i.d. do not
resolve the grievance, the program manager will review the issues and prepare a written



UW HEALTH CLINICAL POLICY 3
Policy Title: Grievance Policy and Procedure for Patients Receiving Care on the Psychiatric Unit or in an AODA or
Mental Health Clinic
Policy Number: 2.4.5

conclusion affirming, modifying or reversing the CRS’s summary, findings and/or
recommendations. The program manager’s report will describe the matters remaining in
dispute, state the findings, state the program manager’s determinations or
recommendations, and state the basis for any modifications to the CRS report.
1. Copies of the program manager’s conclusion should be personally delivered or
sent by first class mail to the grievant (and the patient, if other than the grievant)
and all staff who received a copy of the CRS report within 10 days of the date of
the CRS’s report, unless there is agreement to extend the period of time to allow
for further attempts to resolve the matter.
2. If the grievant (and the patient, if other than the grievant) are in agreement with
the program manager’s conclusion, any recommendations in the report will be
put into effect within an agreed upon time frame.
3. The grievant (and the patient, if other than the grievant) will receive an
explanation of the right to appeal the program manager’s conclusion by filing a
request for administrative review of the conclusion or request to forward the
grievance to the state grievance examiner. A request for administrative review of
a program manager’s conclusion shall state the basis for the grievant’s (and the
patient’s, if other than the grievant) objection, and may include a proposed
alternative resolution.
ii. Emergency Situations
a. Staff who receive a formal grievance in an emergency situation will present the matter to
the program manager. An “emergency situation” means a situation in which, based on
information available at the time, there is reasonable cause to believe that a patient or
group of patients are at significant risk of physical or emotional harm due to the
circumstances identified in the grievance or concern.
b. The program manager will forward the grievance to the CRS as soon as possible, but no
later than 24 hours from receipt of the grievance. The CRS will make the determination
whether an emergency situation exists and should consult with the program manager in
doing so. If after a preliminary investigation, it appears there is no emergency situation,
the CRS may treat the situation as non-emergency for the remainder of the process.
c. The CRS will conduct an investigation and submit a written report to the program manager
within five days. (See V.F.i.b. for content of CRS report.)
d. The program manager will review the CRS report and issue a written conclusion within
five days of receipt of the CRS report, unless the grievant agrees to extend this time
period while attempts are made to resolve the matters still in dispute. (See V.F.i.e. for
content of the program manager’s report.)
G. The grievant (and the patient, if other than the grievant) may agree to suspend a formal grievance (which
suspends all applicable time limits) to attempt informal resolution. Time limits begin running again upon
request of any party to resume the formal grievance process.
H. When a patient’s services are funded by a county agency, grievant (and the patient, if other than the
grievant) may request administrative review by the director of the county agency before appealing to the
state grievance examiner. A grievant (or the patient, if other than the grievant) has 14 days from the date or
receipt of a program manager’s written conclusion to request administrative review. If a grievant (or the
patient, if other than the grievant) expresses intent to pursue administrative review to the program manager
or CRS, then the program manager or CRS will facilitate the request by preparing a written summary stating
the basis for the review and any alternative means to resolve the grievance. The program manager (or
designee) will forward a copy of the original grievance, the CRS report and the program manager’s
conclusion to the director of the county department or state grievance examiner, as appropriate.
I. For further information about the grievance process, contact the Department of Patient Relations at 263-
8009 or, if the patient is on the psychiatric unit, the Nurse Manager of B6/5.

VI. COORDINATION

Author: Nurse Manager, Inpatient Psychiatry; Director, Patient Relations; Director, UW Health Behavioral
Health Services
Senior Management Sponsor: SVP, CNO
Reviewers: Medical Director Hospital Psychiatric Services; General Counsel



UW HEALTH CLINICAL POLICY 4
Policy Title: Grievance Policy and Procedure for Patients Receiving Care on the Psychiatric Unit or in an AODA or
Mental Health Clinic
Policy Number: 2.4.5

Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: August 15, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

UWHC policy #4.46, Responding to Patient/Family Complaints and Grievances
Wisconsin Statutes, Chapter 51: State Alcohol, Drug Abuse, Developmental Disabilities, and Mental Health
Act
Wisconsin Administrative Code, Chapter DHS 94: Patient Rights and Resolution of Patient Grievances

IX. REVIEW DETAILS

Version: Revision
Next Revision Due: November 2019
Formerly Known as: Hospital Administrative policy #10.25