TEXAS NURSE FRIENDLY PROGRAM
 FOR SMALL AND RURAL HOSPITALS
a HRSA funded consultative grant
Information for all hospitals wanting to achieveTNA Nurse-FriendlyÔ designation available at  http://www.texasnurses.org/wkplaceadv/NF/NF.htm

Model Patient Safety and Quality Issue Policy, Product of Texas Nurses Association

Policy and Procedure

Subject:                       Reporting Patient Safety and Quality Issues

Effective date:                       

Policy:  In the course of patient care delivery concerns sometimes arise about the quality of patient care.  It is the policy of ________________ (Hospital or Health Care System) to facilitate the reporting of quality of care issues in a timely manner by any care provider within the _________________________ (Hospital or Health Care System) and to work collaboratively to achieve a positive solution to any identified quality problems. 

Employees or providers with hospital privileges who express in good faith patient quality of care concerns to their supervisor or to the administration of the ___________(Hospital or Health Care System will not be subject to retaliation, discrimination or termination for reporting concerns.

Examples of quality of care concerns include but are not limited to:

• Concerns about provision of care by any:
  • Physician
  • Nurse
  • Ancillary provider of care
• Concerns about patient safety
• Concerns about staffing
• Concerns about patient rights
• Concerns about cultural sensitivity
• Interdepartmental care delivery concerns

Procedure:  Hospital procedures will vary based upon the hospital organizational chart but should include:

• A procedure the concerned individual should follow to report a concern,
• Provide a procedure that outlines how the issue will be addressed in the organization,
• Provide a mechanism that identifies how the reporting individual will be apprised of the outcome if they are not involved in the solution process.
• Identify what protections from retaliation an individual can expect if they make a report.

Provide as a last resort:

·        An avenue for alternative dispute resolution (ADR).

·        ADR alternatives may be very simple such as using a person trained in mediation to assist parties in reaching agreement, using an ombudsman, or using a special group of individuals designated for evaluation of disputes.

·        Such dispute resolution may be internally or externally based.     

Attached to this policy is a model for resolution of nursing quality of care issues that was developed by Texas Nurses Association.  This model or an adaptation of it may be helpful in developing a procedure for resolution of quality of care issues across hospital service units.