The Joint Commission uses information from a variety of sources to strengthen its oversight activities and improve the quality and safety of care in the more than 15,000 health care organizations it accredits and certifies.
Information about health care organizations often comes in the form of complaints from patients, their families, government agencies, the public, as well as from an organization’s own staff, and information from the media. The Joint Commission’s Office of Quality Monitoring evaluates each complaint that relates to safety and quality of care issues, such as patient rights, care of patients, safety, staffing, infection control, medication use and security.
How to report a complaint
Individuals reporting a complaint may provide their name and contact information, or may remain anonymous. Providing a name and contact information enables The Joint Commission to inform the individual about the actions taken in response to the complaint, and also allows The Joint Commission to contact them should additional information be needed. It is our policy to treat someone’s name as confidential information and not to disclose it to any other party. However, it may be necessary to share the complaint with the subject organization in the course of a complaint evaluation. In addition, Joint Commission policy forbids accredited or certified organizations from taking retaliatory actions against employees for having reported quality of care concerns to The Joint Commission.
Report complaints to The Joint Commission online, by e-mail, fax or regular mail.
On-line: www.jointcommission.org/GeneralPublic/Complaint.
E-mail: complaint@jointcommission.org
Fax: Office of Quality Monitoring, (630) 792-5636
Mail: Office of Quality Monitoring
The Joint Commission
One Renaissance Blvd.
Oakbrook Terrace, IL, 60181
Summarize the issue in no more than two pages and provide the name, street address, city and state of the accredited health care organization. For more information, call The Joint Commission’s toll free complaint hot line, (800) 994-6610, 8:30 a.m. to 5 p.m., Central Time, weekdays.
Scope of complaint evaluations
The Joint Commission encourages anyone who has concerns or complaints about the safety and quality of care to bring those concerns or complaints first to the attention of the health care organization’s leaders, which will often lead to more immediate resolution of the matter. Matters concerning billing, insurance, payment disputes, individual personnel or labor relations issues are not within The Joint Commission’s scope. Also, The Joint Commission does not review complaints of any kind in unaccredited organizations.
How The Joint Commission responds to complaints
When a complaint about the quality of care provided by an accredited or certified organization is submitted, The Joint Commission reviews past complaints about the organization, if any, and the organization’s most recent accreditation or certification decision. Depending on the nature of the complaint, The Joint Commission will take one of the following actions:
- Conduct an unannounced or unscheduled on-site evaluation of the organization if the complaint raises serious concerns about a continuing threat to patient safety or continuing failure to comply with standards.
- Ask the organization to provide a written response to the complaint.
- Review the complaint and compliance with related standards at the time of the organization’s next accreditation survey, if it is scheduled in the near future.
- Incorporate the complaint into the quality monitoring database that is used to track health care organizations over time to identify trends or patterns in their performance.
Release of complaint-related information
Upon request from any party, The Joint Commission releases the following information relating to complaints about an accredited or certified organization for the three-year period prior to receipt of the request:
- The number of standards-related written complaints filed against an accredited or certified organization that has met prospective criteria for review.
- The applicable primary standards area involved in a specific complaint review.
- When an unannounced or unscheduled survey is based on information derived from a complaint or public sources, the performance area(s) in which a requirement for improvement was issued will be provided.
If an on-site review of a health care organization results in a change of accreditation or certification status or in requirements for improvement, these changes will be reflected in the organization’s publicly available Quality Report. Quality Reports for accredited organizations are available at www.qualitycheck.org, or by calling the Customer Service Center, (630) 792-5800.
4/08