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VUMC Policy
Vanderbilt University Medical Center has established a Patient Complaint Monitoring Committee (the 'Committee') which is a standing committee of the Medical Center Medical Board. As a medical review committee (pursuant to T.C.A. 63-6-219), this committee will use the patient complaint methodology developed, reported, and described in an article entitled Development of an Early Identification and Response Model of Malpractice Prevention, published in Law and Contemporary Problems, Vol. 60, No. 1, Winter 1997.
All Vanderbilt Medical Group (VMG) physicians will be assessed using this methodology, using the data currently available through the Office of Patient Affairs patient complaint system. In addition, special attention will be paid to new faculty, who will be assessed closely for a period of 12-18 months after hire. Feedback will be given on a regular basis to the Chairs on all new hires during this period of time.
VMG physicians assessed by the patient complaint methodology whose complaints by number and nature warrant review shall received a visit from a trained VMG physician messenger who will communicate to the physician the patient complaint data and the methodology that documents his/her risk profile. The messenger should not be the Department Chair. The individual's Department Chair will be informed about this initial visit if the complaint suggests inappropriate physician behavior or behavior that may endanger the health and safety of patients or others, or if the Patient Complaint Monitoring Committee determines the Department Chair should be informed. This messenger will provide an assessment of the visit to the Patient Complaint Monitoring Committee. This will be known as Level I Intervention.
Following this initial messenger visit, the physician profile will generally be monitored for up to 12 months. If, at the end of that time, improvement has been judged to be satisfactory as evidenced by significant reduction in complaints and other relevant factors, the physician will resume the regular rate of monitoring of all faculty. However, if the patient complaints status does not improve, a second intervention with the physician will be carried out. This will be known as a Level II Intervention. It will be tailored to the extent and severity of the problem, but will include a second messenger visit. In addition, at this point the situation will be discussed with the Department Chair. All such physicians will be counseled by both the messenger and the Department Chair and depending on the nature of the complaints, may be required to do one or more of the following:
- Referral to the Physician Wellness Program (PWP)
- The PWP is part of VUMC Work/Life Connections-EAP Program
- Take a course in risk management
- Take a course in improving communication skills
- Redesign the clinic/office management system(s)
- Evaluate staff performance and/or staffing levels
- Other similar measures, as deemed appropriate
Following this Level II Intervention, the committee will continue to monitor patient/family complaint data. Regular updates, at least every six months, will be provided to the Department Chair. If improvement occurs during the next 12 months, the physician may resume the regular monitoring program. However, if significant improvement has not occurred, a Level III Intervention will be initiated. This Level III Intervention will be the responsibility of the Department Chair in consultation with the Chief of Staff, the Patient Complaint Monitoring Committee, and others as indicated. Options include:
- Continued counseling and follow up by the Chair of the Department
- Initiation of Informal Counseling or Corrective Action pursuant to the Medical Staff By-Laws as warranted
- Initiation of Corrective Action pursuant to the Faculty Manual as warranted
