| Grievance / Complaint Log | W.G.M. Rivero MD · FPCP · DPSN · · renalcarematters.com · 2026 |
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Patient-Experience & Risk Workflow · Section 6.8
Grievance / Complaint Log
One form per incident — intake, investigation, and resolution — plus a monthly rolling log, for the Grievances / complaints metric (PSN metric, monthly cadence) in the Dialysis Center QAPI vs. CQI field manual, Section 6.8.
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W.G.M. Rivero MD
FPCP · DPSN Nephrology
renalcarematters.com
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7 Categories tracked, matching the intake checklist |
3 Pages — intake & investigation, then the monthly rolling log |
Monthly Rollup feeds the QAPI Scorecard's grievance line |
📥 1 · Intake Open one intake form (below) the day a grievance or complaint is received — verbal or written. |
🔎 2 · Investigate Complete the investigation & resolution page (page 2) before the case is closed. |
📊 3 · Roll Up Transfer date, category, severity, and status to the monthly log (page 3) and total it for the Scorecard. |
A grievance is any expression of dissatisfaction — about care, staff, scheduling, billing, or the environment — that a patient, family member, or caregiver wants addressed, whether or not it is put in writing. Log every one, including those resolved on the spot; the count and resolution time are what the QAPI dashboard tracks, not just the unresolved ones.
Clinical CareScheduling / Wait TimeStaff CommunicationBilling / FinancialFacility / EnvironmentTransportationOther
| Date received | Time | Patient initials (no other Personal Health Information (PHI)) | Received by | How received☐Verbal ☐Written |
Category (check all that apply)
| ☐Clinical Care | ☐Scheduling / Wait Time | ☐Staff Communication | ☐Billing / Financial |
| ☐Facility / Environment | ☐Transportation | ☐Other: | |
Severity — Low routine dissatisfaction, no harm · Medium care/process concern, no lasting harm · High alleged harm, safety concern, or regulatory/legal exposure — escalate to the DCH the same day.
| ☐Low | ☐Medium | ☐High — notify DCH same day |
Description, in the patient's / complainant's own words
Immediate action taken at intake (if any)
| Educational data-collection aid. Not a validated accreditation instrument or a substitute for your PSN/DOH-required grievance documentation. No PHI beyond initials belongs on this sheet. | renalcarematters.com Page 1 of 3 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |
Grievance / Complaint Log — continued Investigation · Resolution · Sign-Off |
Page 2 of 3 · renalcarematters.com |
Findings / root cause (use the Fishbone or "5 Whys" from Section 7 of the field manual for anything beyond a simple fix)
| Investigated by | Date completed | Escalated beyond unit level?☐No ☐Yes — to: |
Corrective action taken (system fix, not just an apology — what changes so this doesn't recur?)
| Resolution date | Days to resolve | Patient / complainant notified?☐Yes ☐No | Satisfied with resolution?☐Yes ☐Partial ☐No |
Every closed case here adds to the "Grievances this month / resolved" line in Section 6.8 of the QAPI Scorecard. A cluster of grievances in one category (e.g. three "Scheduling / Wait Time" cases in a month) is itself a special-cause signal — open a Plan-Do-Study-Act (PDSA) charter or take it to the fishbone in Section 7, don't just close the individual cases.
| Investigated by | Reviewed by (DCH) | Date closed |
| Educational data-collection aid. Not a validated accreditation instrument or a substitute for your PSN/DOH-required grievance documentation. | renalcarematters.com Page 2 of 3 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |
Grievance / Complaint Log — continued Monthly Rolling Log · Trend Summary · Ready for the Meeting |
Page 3 of 3 · renalcarematters.com |
| Unit / facility name | Reporting month | Prepared by |
| Date | Category | Severity | Status | Days to resolve | Notes |
|---|---|---|---|---|---|
| Metric | This month | Note |
|---|---|---|
| Grievances received | count | |
| Grievances resolved | = entries with a resolution date | |
| Still open at month-end | carry forward; flag if > 30 days | |
| Mean days to resolve | trend down | |
| Most frequent category this month | candidate for a PDSA / fishbone | |
| High-severity cases | each reviewed at DCH level |
| ☐Every case this month has an intake & investigation page ☐All closed cases have a resolution date ☐High-severity cases reviewed with the DCH | ☐Monthly totals transferred to the QAPI Scorecard ☐Category clusters flagged for PDSA / fishbone review ☐Open cases carried to next month's log |
Type these totals into the Dialysis Unit QAPI Scorecard (renalcarematters.com/guides/calc-dialysis-qapi-scorecard.html), then bring any category cluster or high-severity case to the Monthly CQI Meeting Walkthrough (renalcarematters.com/guides/calc-qapi-meeting-wizard.html) for discussion and, if warranted, a PDSA charter.
| Educational data-collection aid. File this log alongside your PSN/DOH-required grievance documentation. Does not replace your facility's formal grievance-resolution policy. | renalcarematters.com Page 3 of 3 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |