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Grievance Process: Concerns Regarding Your Care

Memorial Hospital endeavors to meet its patients' expectations for care and services in a timely, reasonable and consistent manner. Patients (and/or their immediate family or personal representatives) have the right to submit a complaint, verbally or in writing, 24 hours per day. Memorial Hospital, through its Board of Trustees, has adopted the following process to help with any complaints or grievances you may have regarding your hospital experience:

Step 1: Prompt Resolution for Verbal Complaint

If a patient submits a verbal complaint to a Memorial Hospital staff member who is present or another staff member is quickly available and the patient is satisfied with the actions taken on his or her behalf, the complaint is considered resolved.

Step 2: Filing a Grievance

If a verbal complaint is not promptly resolved to the patient’s satisfaction by the Memorial Hospital staff under Step 1, or if a patient submits a written complaint, the Memorial Hospital staff member will forward the complaint to a patient representative at Memorial Hospital by the next working day. Patients may also file a grievance, verbally or in writing, 24 hours per day by contacting a patient representative at (719) 365-5621. The patient representative will contact the patient within three (3) working days of receipt of the grievance to acknowledge having received the grievance.

Patients may also file a grievance with the Colorado Department of Public Health and Environment, Executive Director Health Facilities Division, 4300 Cherry Creek Drive South, Denver, CO 80246, Phone: 1-303-692-2800 or Toll Free: 1-800-886-7689, ext. 2800.

You may also contact the Colorado Department of Regulatory Agencies at 303-894-7855 or toll-free 1-800-886-7675.

Medicare Beneficiaries:

If the grievance concerns quality of care or premature discharge from the facility for a Medicare beneficiary, the patient representative will immediately refer the grievance to case management. At the patient’s request, the grievance will be referred to the Hospital Quality and Patient Safety Committee of the Board of Trustees. Patients also have the right to appeal an impending hospital discharge.

Step 3: Investigation

a.) The patient representative will investigate the grievance and respond to the patient, on average, within seven (7) working days, but up to fifteen (15) working days of the submittal of the grievance. Grievances regarding possible endangerment of the patient, such as neglect or abuse, will be investigated and addressed immediately. If the patient representative is not available (such as after-hours/weekends/holidays), any grievance requiring immediate attention will be referred to the clinical manager or director, if available; the patient services administrator; or the nursing director on-call, depending on the nature and scope of the grievance.

b.) After investigation, which may include a meeting with the patient and his/her family, and appropriate input from management and others, the patient representative will provide the patient with a written report regarding the hospital's decision regarding the grievance, which includes:

i.) The name of the patient representative or other hospital contacts;

ii.) The steps taken by the hospital on behalf of the patient to investigate the grievance;

iii.) The results of the grievance process; and

iv.) The date of completion.

The grievance is considered resolved when the patient is satisfied with the actions taken on his or her behalf.

Step 4: Dissatisfaction

If the patient is dissatisfied with the patient representative's report, at the patient’s request, the patient representative will either (i) forward the grievance and the report to the Department of Public Health and Environment or (ii) forward the grievance to the Memorial Hospital CEO (or his/her designee). The CEO’s designees for grievances will include the following individuals based on the underlying nature of the grievance:

A. Medical Staff / Physician Issues: Chief Medical Officer

B. Hospital Operations / Hospital Staff Issues: Chief Operating Officer

C. Medicare Beneficiary Billing Issues: Chief Financial Officer

D. Legal Issues: Legal Counsel

E. Confidentiality Issues: Privacy Officer

Within ten (10) working days of receiving the forwarded grievance, the CEO (or designee) will investigate the grievance and report the findings to the patient in writing.

If the patient remains dissatisfied with the CEO's (or designee's) report, the patient will be informed that the patient representative will forward the grievance and the report to the Department of Public Health and Environment at the patient’s request. The patient may also file the grievance directly with the Department.

Memorial Hospital is a Joint Commission-accredited organization. Patients may also contact the Joint Commission if they feel a patient safety or quality of care concern has not been addressed to the patient’s satisfaction. The Joint Commission Office of Quality Monitoring may be reached at:

Toll free: 1-800-994-6610
Fax: 1-630-792-5636
Mail: The Joint Commission, Office of Quality Monitoring, One Renaissance Blvd. Oakbrook Terrace, IL 60181

Communication: Every effort will be made to provide information in a manner and form that can be understood by the patient or family. This will include interpretation of the grievance process and other information into the language of the non-English speaking patient, use of alternative communication techniques or aides for those who are hearing-or visually-impaired or taking other steps as needed to effectively communicate with the patient.

For patients, companions and families who prefer to communicate in Spanish, Memorial Hospital can provide professional face-to-face interpreters free of charge. For many other languages, we can provide an interpreter over the phone at no cost. Interpreters can help you communicate with your doctors, nurses, and others, and can interpret for you when you are having a test or procedure performed.

If there is important written information that you need translated into your preferred language, we may be able to provide a translator (face-to-face for Spanish; via the Pacific Interpreter Phone Line for other languages) and a member of your health care team to help you understand the information. If you, a family member or loved one communicate using sign language, the Sign Language Network can provide you with a certified sign language interpreter at no cost to you.

If you or your companion(s) require any of these services, please let registration staff or your nurse know.

For more information on Memorial Hospital's grievance process, contact a patient representative by calling 719-365-5621.

Grievance Procedure under Section 504 and Title II of the Americans with Disabilities Act of 1990

In accordance with the requirements of Section 504 of the Rehabilitation Act of 1973 (Section 504) and Title II of the Americans with Disabilities Act of 1990 (Title II of the ADA), Memorial Hospital (MH) does not discriminate on the basis of disability in admission or access to, or employment or treatment, under any MH program or activity. MH does not retaliate or discriminate against, or coerce, intimidate, or threaten any individual who (1) opposes any act or practice made unlawful by Section 504 or Title II of the ADA; or (2) files a grievance and/or complaint, testifies, assists, or participates in any investigation, proceeding, or hearing under Section 504 or Title II of the ADA.
MH has adopted an internal grievance procedure providing for prompt and equitable resolution of grievances alleging any action prohibited by Section 504, Title II of the ADA, or the Federal regulations implementing these laws.  The applicable Federal laws and regulations may be examined by contacting the office of:
Lauren Haley
Accessibility Coordinator
Memorial Hospital
1400 E. Boulder Street
Colorado Springs, CO 80909
Voice (719) 365-8581
Ms. Haley has been designated to coordinate the efforts of MHS to comply with Section 504 and Title II of the ADA.
Any person who believes he/she has been subjected to discrimination on the basis of disability or who believes he/she has been subjected to retaliation under Section 504 or Title II of the ADA may file a grievance under this procedure.  It is against the law for MH to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance.


1. Grievances must be submitted to MH’s Accessibility Coordinator (or designee) or Patient Representatives as soon as possible but no later than sixty (60) calendar days after the date the person filing the grievance becomes aware of the alleged discriminatory action.  

2. If the grievance is filed with a Patient Representative, he/she will work with the Accessibility Coordinator to resolve the grievance.

3. A grievance must be in writing, containing the name and address of the person filing it. The grievance must state the problem or action alleged to be discriminatory and the remedy or relief sought.

4. MH’s Accessibility Coordinator (or designee) will conduct an investigation of the grievance. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the grievance. MH’s Accessibility Coordinator will maintain the files and records of MH relating to such grievances.

5. MH’s Accessibility Coordinator will issue a written decision to the individual on the grievance no later than thirty (30) calendar days after its filing.

6. The person filing the grievance may appeal the decision of MH’s Accessibility Coordinator by writing to the Chief Operating Officer, or designee, within fifteen (15) calendar days of receiving MH’s Accessibility Coordinator’s decision.

7. The Chief Operating Officer, or designee, will issue a written decision in response to the appeal no later than thirty (30) calendar days after its filing.

8. Filing a grievance with MH’s Accessibility Coordinator (or designee) does not prevent the person, patient and/or his/her family member or guardian from filing a complaint with the:
Office for Civil Rights, Region VIII
U.S. Department of Health and Human Services
999 18th Street, South Terrace, Suite 417
Denver, Colorado 80202
Voice Phone (800) 368-1019
FAX (303) 844-2025
TDD (303) 844-3439
9. MH personnel, including Patient Representatives, will assist interested persons in filing grievances and will forward completed grievances to MH’s Accessibility Coordinator for investigation or other appropriate action.
MH’s Accessibility Coordinator (and/or designee) will make appropriate arrangements to ensure that people with disabilities are provided reasonable modifications and appropriate auxiliary aids and services where necessary to participate in this grievance process. Such arrangements may include making the grievance procedure available in alternate formats such as Braille, large print, audiotape, providing interpreters for the deaf or hard of hearing, assuring a barrier-free location for proceedings, or providing foreign language interpreters.

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