PATIENT FEEDBACK

Effective Date: 
Tue, 05/18/2021
Reviewed: 
Wed, 08/18/2021
Policy: 

In order to best serve the patients/families of our community, the UCSC Student Health Center is committed to soliciting and receiving feedback for continuous improvement. Feedback, both positive and negative, gives us unique opportunities for evaluating our delivery of care and improving internal systems and processes. A key component of patient feedback management is the systematic recording of feedback and its resolution, which is achieved through a feedback management system. The UCSC Student Health Center uses an electronic feedback management system (EFMS) called the RL Datix Feedback Module.

To be patient centered, UCSC Student Health Services evaluates patient satisfaction in multiple ways - via Quick Comments, ongoing patient surveys, benchmarking surveys within the UC system as well as unsolicited communications. The UCSC Student Health Center monitors feedback from patients, family members and concerned others via its Quality Management Committee. All feedback will be acknowledged and responded to in a timely, professional and appropriate manner. Several mechanisms will be used to collect ongoing patient feedback. A key component is the systematic recording of feedback and resolution through the electronic feedback management system (EFMS), RL Datix. Feedback is logged into the EFMS to identify trends. The aggregate data is available in order to assist in departmental quality improvement initiatives. High level insights are also shared on a quarterly basis with the Quality Management Committee, the Clinical Operations Committee and the Governing Body.
In accordance with the University of California Office of General Counsel (OGC) Guidance on Red Flags for Potential SVSH Allegations in the Patient Care Setting, the following terms, when used by faculty, staff, trainees, or patients when making complaints or providing other formal or informal feedback or evaluations, may be “red flags” for sexual misconduct or other boundaries violations. Red flags are generally defined as circumstances which could place a reasonable person on notice that improper conduct has or may have occurred. The asterisks below indicate that there may be multiple versions of a word or word root, for example “creepy, creeped-out, creep” or “flirty, flirtatious, flirted, flirt”.
assault*, caress*, creep*, exposed, flirt*, fondle*, grope*, handsy, harass*, innuendo, molest*, pervert, pervy, rape, raped, raping, rapist, sexual, SVSH, touchy, undress*, uncomfortable, violating
Feedback received related to these words should be entered into the EFMS and escalated to Title IX.

The objectives of this policy are to:
1. Assist the UCSC Student Health Center with the timely and effective management of feedback occurring within or related to the Student Health Center.
2. Establish a standard approach to handling feedback.
3. Ensure that all staff are aware of their responsibilities and are empowered to manage or report feedback.
SCOPE
This policy applies to all feedback from patients, families, and concerned others about services received at the UCSC Student Health Center. This policy applies to all UCSC Student Health Center employees.
DEFINITION(S)
I. Feedback: Verbal or written communication expressed in regards to an experience with the Student Health Center. It can be positive or negative in nature. It may be communicated in person, online, by phone, via secure message, through a written comment, etc. Written feedback can be received through the following sources: Patient feedback forms (aka Quick Comments) available in waiting areas, Open-ended comments in Satisfaction Surveys, unsolicited emails or letters.
A. Compliment: An expression of satisfaction or commendation with any aspect of the services or care provided by an individual, department or organization
B. Inquiry/Support: Request for information, education, support or advice regarding personal experience, general systems issues or how the healthcare system works. Inquiries/Support are not entered into the EFMS. Examples include but are not limited to:
1. Insurance waiver issues
2. Immunization compliance issues (with no care concerns)
C. Comment/Suggestion/FYI (hereafter referred to as “comment”): An idea or plan put forth for consideration and/or anonymous written feedback unrelated to clinical care provided. Comments do not require patient follow-up and may be escalated on a case by case basis. Examples include but not limited to:
1. Anonymous review regarding our scheduling system
2. Suggestion for aesthetic modifications
D. Complaint: Verbal dissatisfaction, unrelated to clinical care provided, that can be resolved promptly at the point of service (or within 24 hours) by the staff present. Examples include but not limited to:
1. Patient was upset with the wait time for a visit and informed staff
2. Patient had billing issues (with no care concerns)
E. Grievance: Verbal dissatisfaction that cannot be resolved promptly (within 24 hours) and all written dissatisfaction related to services provided.
F. Incident: An event consistent with the UCSC Student Health Center’s Incident Management Policy.
II. Point of Service: Where the feedback has originated or where the interaction first occurs. It is the connection between the Student Health Center and the patient/family. This is where the complaint is expected to be resolved, whenever possible.
III. Service Recovery: A courtesy gesture to enhance a patient’s satisfaction. This can include fee waivers, fee reversals, and complementary service(s).
A. Proactive Service Recovery: a gesture offered in the absence of patient complaint
B. Reactive Service Recovery: a gesture offered as a result of a complaint or grievance
IV. Assistance: An action taken to enhance a patient’s satisfaction. This can include scheduling help, insurance clarification, etc.
Patient Feedback Report: A submission of patient/family feedback into the EFMS
VI. Passive Feedback: Several mechanisms will be used to collect ongoing feedback, including but not limited to:
A. “Quick Comments” available in our waiting areas
B. Invitation on our website to provide feedback
C. A culture of listening to patients and families respectfully as they provide feedback
D. Empowerment of practice team members to encourage patients and families to reach out directly with specific comments, questions, or concerns
VII. Proactive Feedback: Several mechanisms will be used to collect ongoing feedback, including but not limited to:
A. Periodic patient surveys
B. Input from student groups
VIII. Feedback Category: A classification used to categorize feedback themes
IX. Resolution Summary: A recommended action for each patient feedback report

 

Procedure: 

I. COMPLIMENTS:
A. Compliments are forwarded to the department manager
B. The compliment will be shared with the person(s) identified by their manager.
C. If patient contact information is available, the manager sends an acknowledgement to the sender within three business days (see Appendix A3).
II. COMMENT/SUGGESTION/FYI
1. A representative from the Quality Management Committee to collect Quick Comments from one of our five drop off areas daily and give to our Business and Information Services Director (BISD) for entry into EFMS. The BISD is a member of the Quality Management Committee and a Quality Representative.
A. Within 2 business days, the BISD will:
a. Confirm that feedback is a comment. The report will be re-tagged as a grievance or incident if appropriate
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow- up.
C. If the patient included their contact information, the appropriate manager sends acknowledgement within three days (see Appendix A.1). In order for the communication to remain secure, it is recommended communications be sent through Secure Message or the secure Virtru email system.
D. All correspondence with the patient/family will be uploaded and attached to the report.
E. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
III. COMPLAINT
A. When a complaint is received, an attempt will be made to resolve the complaint immediately and/or within 24 hours, involving the provider or manager where appropriate. Escalation of complaints may be avoided where staff have clear authorization to resolve the complaint at the point of contact. If the complaint is resolved without issue, the matter is deemed concluded.
Complaints resolved within 24 hours are submitted to the chair of the Quality Management Committee (who will serve as the Quality Representative) and entered as a Patient Feedback Report in the EFMS
B. Within 2 business days, the Quality Representative will:
a. Confirm that feedback is a complaint. The report will be re-tagged as a grievance or incident if appropriate
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow- up.
C. If the patient included their contact information, the appropriate manager sends the patient an acknowledgement email within 3 business days (see Appendix A.1). In order for the communication to remain secure, it is recommended communications be sent through Secure Message or the secure Virtru email system.
D. All correspondence with the patient/family will be uploaded and attached to the report.
E. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
F. It is the responsibility of the manager to identify trends and submit complaints received and resolved on their unit(s) in the EFMS if:
. there is a risk of the complaint escalating;
a. the complaint(s) suggests a pattern that involves a provider, department, and/or the organization/system;
b. the complaint involves more than one department and/or has organization/system wide impact.
IV. SOCIAL MEDIA
A. UCSC Student Health Services maintains the following social media accounts
 CARE-Instagram
 CAPS Peer Educator Program-Instagram
 SHOP-Instagram
 CAPS-Facebook
It is the responsibility of each department to monitor their sites for comments related to Student Health Services and copy the comment and response into a Patient Feedback Report in the EFMS and also report to their supervisor. Official UCSC Social Media accounts are monitored by UCSC Public Relations and they inform the Student Health Center of any comments related to Student Health Services, which are forwarded to the appropriate department manager for entry.
B. When a UCSC Student Health Center employee becomes aware of patient/family feedback on a social media platform that information is forwarded to the appropriate department manager for entry.
C. When a Social Media comment is received by the Quality Representative, it will be
acknowledged within two (2) business days and the sender will receive information on how to submit non-anonymous feedback for response/action (see Appendix B).
D. The Quality Representative will:
a. Confirm the feedback is a comment. The report will be re-tagged as a grievance or incident if appropriate.
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow-up.
E. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
V. ANONYMOUS PATIENT FEEDBACK SURVEY:
A. All free-text feedback entered by patients in anonymous patient feedback surveys will be reviewed by the relevant Quality Representative. The Quality Manager in this case will be whichever member of the Quality Management Committee is analyzing the data.
B. The Quality Representative will:
a. Enter individualized feedback per provider as an individual report into the EFMS.
b. Assign Feedback Category (see section 1) c. Ensure that multiple, similar anonymous comments from the same survey will be aggregated and entered as one in the EFMS.
d. Task the appropriate manager for further investigation and follow-up.
C. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
VI. GRIEVANCE
A. All grievances are submitted to the chair of the Quality Management Committee (who will serve as the Quality Representative) and entered as a Patient Feedback Report in the EFMS preferably within 24 hours.
B. Within 2 business days, the Quality Representative will:
a. Confirm that feedback is a grievance.
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow-up.
d. If contact information is provided the Manager sends the patient an acknowledgement email or secure message within 3 business days (see Appendix A.3). In order for the communication to remain secure, it is recommended that communications be sent through Secure Message or the secure Virtru email system.
e. Manager adds follow-up when action(s) completed.
f. All correspondences with the patient will be uploaded and attached to the Patient Feedback Report.
g. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
VII. INCIDENT
A. If a Patient Feedback Report falls within the definition of an incident, the Quality Representative will task the Patient Feedback Report to a member of the Quality Management Committee, who will submit an incident report in the electronic risk management system.
B. Response/action will be determined by the Quality Management Committee (See Adverse Incidents policy).
C. Resolution Summary determined (see Section 2) and event closed in the EFMS.
REFERENCES
- Adverse Incident Policies:
http://shs-manual.ucsc.edu/policy/incident-reports-0
http://shs-manual.ucsc.edu/policy/incident-management-plan
http://shs-manual.ucsc.edu/policy/iij-incident-policy http://shs-manual.ucsc.edu/document/medication-error-reduction-2

SECTION 1: Feedback Categories
1. Accessibility
2. Accommodation
3. Attitude/Courtesy
4. Care/Treatment
5. Communication
6. Coordination & Continuity of Care
7. Environment
8. Financial
9. Information
10. Loss
11. Patient Rights & Responsibilities
12. Responsiveness
13. Safety
14. Service

SECTION 2: Resolution Summary
1. Apology
2. Bill Waived
3. Acknowledgement
4. Refer to Human Resources
5. Refer to Medical Director
6. Refer to Business Operations
7. Refer to Director, Clinical Operations
8. Supervisor discussion of informal improvement plan with staff
9. Supervisor develops formal improvement plan with staff with monitoring as needed
10. Propose change to system
11. Educate all staff
12. Monitor system
13. Documentation of procedures
14. Policy instituted/reviewed/revised
15. Staffing pattern/workflow modified
16. Communications process enhanced
17. Discuss with patient/family
18. Engage in service recovery
19. Discuss with staff involved
20. Assistance
21. Refer to Risk Management Committee
22. No further action warranted
23. 805 Report
24. NPDB Report
25. Title IX Report

APPENDIX A

Follow-up Email Templates
1. Acknowledgement of Patient Comment/Suggestion/FYI Received Subject: Patient Feedback Follow-up
Greetings,
This email is to acknowledge your feedback regarding your recent experience at the UCSC Student Health Center. We appreciate you bringing this to our attention and allowing us the opportunity to review our practices.
The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care.
Should you have any further comments, please do not hesitate to reach out. Kind Regards,

2. Manager’s Positive Patient Feedback Follow-up Subject: Patient Feedback Follow-up
My name is XXX and I am the _____ Manager at the UCSC Student Health Center here on campus.
Thank you for providing feedback about your recent experience. The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care.
Best,

3. Manager’s Negative Patient Feedback Follow-up Subject: Patient Feedback Follow-up
My name is XXX and I am the ____ Manager at the UCSC Student Health Center here on campus. I received the feedback you provided about your recent experience. I apologize and appreciate you bringing this to our attention. We are committed to exceptional service to all of our patients. The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care.
Please let us know if you would like to schedule a time to discuss your concerns.
Best,

APPENDIX B
Social Media Response Script
Positive Review:
Thank you for taking a moment to review your experience at the UCSC Student Health Center.
The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care. If you would like to personally recognize any of the staff, please feel free to send them a compliment here: healthcenter@ucsc.edu

Negative Review:
Thank you for taking a moment to review your experience at the UCSC Student Health Center. We appreciate your feedback. The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care. We would like to discuss your recent visit with you in more detail. Please let us know at healthcenter@ucsc.edu if you would like a Student Health staff member to be in touch with you to discuss this further. Thank you for your time and feedback.

ATTACHMENT 1 (Sample) Patient/Family Feedback Policy Summary

Feedback Types Type Definition Example(s)
Compliment
Expression of satisfaction with any aspect of the services or care provided by an individual,
department or organization
Positive provider review from Inquiry/Support Request for information, education, support or advice regarding personal experience, general systems issues or how the healthcare system works. Insurance waiver issues; Immunization compliance issues (with no clinical concerns)
Comment/Suggestion/FYI
An idea or plan put forth for consideration and/or anonymous written feedback unrelated to
clinical care provided
Anonymous review regarding system; Suggestion for aesthetic
Complaint

Verbal dissatisfaction that can be resolved promptly at the point of service (or within 24 hours) by the staff present and is unrelated to clinical care provided Patient dissatisfied with the wait and informed staff
Grievance
Verbal dissatisfaction that cannot be resolved promptly (within 24 hours) and all written dissatisfaction related to services provided
Written negative feedback with information; Free-text on anonymous feedback survey; Free-text expressed social media profile managed Student Health Center
Incident

An event consistent with UCSC Student Health Incident Management Policy See Policy http://shs-manual.ucsc.edu/policy/incident