Benjamin Franklin once famously quipped “nothing is certain but death and taxes.” However, Franklin did not work in a jail, otherwise he would have said: “Nothing is certain except death, taxes and grievances.”

On the outside, patients do not write grievances—they vote with their feet. If they dislike the medical care they are receiving, they will just go to a different doctor. In a jail, they cannot do this. We have a grievance system in Correctional Medicine because our patients cannot fire us (and we cannot fire them–discussed previously here). If jail patients are unhappy with their medical care, their only recourse is to write a grievance.

Grievances are not necessarily bad things. A medical grievance is sometimes the way by which jail patients alert us to significant problems that we may have not known about or mistakes that we made. I myself have had my butt saved in this manner—more than once! Many grievances are simply about communication errors. We have not yet adequately explained a medical decision to the patient.

Yet jail medical personnel often have a bad attitude about grievances. This is unfortunate, because medical grievances are an important—even essential—part of the jail medical system. I believe that the most important reason for the bad attitude is that people have not been taught how to write a proper grievance response. That, then is the topic of today’s JailMedicine post.

Stripped of all of its emotional overlay, the grievance is a simple question about medical care. However, since this question is often accompanied by angry and demanding language, it tends to illicit angry and defensive emotions. In order to write a good grievance response, it is important to get past this emotional overlay and just focus on the question being asked. Done well, and the patient will feel understood and, even if they do not receive what they want, the matter will be resolved. Done poorly, and the patient will be even more hostile and plan their next move. The matter is not resolved and will have to be re-addressed later.

It is also important to remember that the grievance response may later be read by a patient advocate, such as a plaintiff’s attorney or the ACLU. A poorly written grievance will indicate that you are denying reasonable medical care and have a bad attitude to boot. A good grievance response will show that the patient’s question was thoughtfully addressed and no essential care was denied.

Who should write the grievance response?

The first question to be answered is who should answer the grievance. Initial grievances should be answered by medical person with greatest knowledge about the question being posed. A grievance relating to nursing care (“I was not offered my medications this morning!”) should be answered by a nurse. This person may be the Director of Nursing or another nurse assigned by the DON. Similarly, dental complaints should be answered by the dentist, mental health complaints should be answered by mental health and grievances about medical care should be answered by a practitioner, usually assigned by the Medical Director.

One question that often comes up is that if the grievance is about a specific person (“Nurse Joan was rude to me!”), should that person (Nurse Joan) respond or someone else? My feeling is that it should be someone else. Otherwise it puts Nurse Joan into the position of either arguing (“No I wasn’t! You were rude to me!”) or feeling like she has to apologize even if she felt she did nothing wrong. It is better in my book to have someone else evaluate the complaint and write the response.

What if the patient appeals the grievance? Grievance appeals should be answered by a different person with equal or higher authority. For example, if a nurse answered the first grievance, the Director of Nursing could answer an appeal. The Medical Director of the facility can answer any type of appeal, whether nursing, dental or mental health. In some cases, the jail commander should be the person to answer a medical grievance or an appeal, especially if the grievance is abusive (discussed in more detail below).

What is the time frame for grievance responses?

In my opinion, grievance responses should be written as soon as possible, certainly no more than a week later. An immediate grievance response tells the patient that you are taking their concerns seriously and care about your reply. Waiting a long time to respond tells the patient that they are not important and gives them time to get angrier and maybe write other letters of complaint. It is always in our best interest—as well as the best interest of the patient—to respond quickly. In my grievance replies, I list the date the date the grievance was written (or the date I received it if it sat on someone’s desk for a while: “This is a response to a grievance dated January 25, 2019 and received by me January 30, 2019.”

How should the grievance reply be written?

This is how I personally respond to grievances.

Step one: Put in the essential information.

Grievance replies do not have to be formal letters, but do need to include the basics: the date, the facility, what patient wrote the grievance and when, who is writing the response, and the fact that this is a grievance response.

• Date: 1/25/2019
• Facility: Nurmengard Correctional Facility
• “This is a response to a grievance written by Tom Marvolo Riddle, dated 1/24/2019.”

Step two: Restate the question.

The first sentence of the grievance response should restate the question being asked. Again, it is important to avoid reacting to or using emotional language. I prefer to write grievance replies in the third person—it feels more detached and less argumentative when I do it this way (though others disagree and feel the grievance reply should address the patient in the first person).

• “In this grievance, Mr. Riddle states that he asked for a second mattress and this request was denied.”

Sometimes it works to quote what the patient stated in their grievance directly:

• “Mr. Riddle states “I am being denied medical treatment for my chronic pain.”

Step three: Tell what you did to evaluate the grievance.

After restating the complaint, the next step is to list all the things you did to investigate the validity of the complaint. This includes the materials you reviewed (like medical records), the people you talked to and the research you did. This is important, because it shows that you took the grievance seriously by looking at all aspects of the complaint.

• I have reviewed Mr. Riddle’s medical record, talked to the practitioner involved and also reviewed medical records from Mr. Riddle’s outside medical provider.

Step four: State your conclusion.

In my opinion, this should not be a long, detailed rebuttal. This should be a short summary of your conclusion—one or two sentences at most. You are going to offer to go into more detail about this issue in the next step.

• As was discussed with Mr. Riddle during his clinic visit, a second mattress is not a medical device or prescription. His outside medical records do not show any mention or order for medical bedding. This is not a medical issue.

• “I have discussed Mr. Riddles’ case directly with his outside pain management specialist, Dr. Pomfrey. We are in agreement about the care to be provided while Mr. Riddle is incarcerated.”

Step five: Offer to discuss the issue in more detail in medical clinic.

• “Mr. Riddle may certainly discuss this issue in more detail in medical clinic, if he wishes.” Or “I note that Mr. Riddle is already scheduled be seen in the medical clinic where we can discuss the case in more detail.”

What if the patient is right?

In my experience, medical grievances often have merit in whole or in part. When this is the case, we should admit this, thank the patient for bringing this to our attention and say what we are going to do to remedy the situation.

“Mr. Riddle states that he is supposed to be taking buspirone twice a day, but since arriving at the jail, it has only been dispensed once a day. I have reviewed the medical record and note that Mr. Riddle is correct. I will rewrite the order for twice a day and insure that it is on the cart twice a day. I will also talk to Mr. Riddle directly in medical clinic.”

What if the patient is abusing the grievance system?

Inmate patients sometimes cross the line into unacceptable behavior in their grievances. Examples include using unacceptable language, calling medical providers names and writing repetitive or trivial grievances. These usually should be given to the jail commander, who can both reply and decide on appropriate discipline.

Putting it all together. Here is an example grievance response:

Patient: Barty Crouch, Jr.
Jail: Nurmengard Correctional Facility
Date: 2/13/2018

Response: This is a response to a grievance dated 2/12/18 in which Mr. Crouch states that his complaint of rectal bleeding has not been adequately evaluated by medical services. I have reviewed his medical record and spoken to the practitioners who saw Mr. Crouch. I note that Mr. Crouch was seen for this complaint originally on 1/8/18, and had a normal rectal exam with no blood found by chemical testing. Mr. Crouch was scheduled for routine follow up in the medical clinic on 1/22/18, and denied at that visit that he was still having rectal bleeding. Mr. Crouch has submitted no requests to be seen by medical since then. It appears to me that Mr. Crouch has been appropriately assessed for his original complaint. However, since Mr. Crouch’s symptoms have returned, I have scheduled him to be re-evaluated at the next medical clinic.

I have added a Sample Guideline for Grievance Responses to the Sample Guideline Page found on the JailMedicine main page!

As always, what I have written here is my opinion, based on my own training and experience. I could be wrong! You may have a better method for responding to grievances. If so, please tell us how you do it in Comments!