SAMPLE POLICY WORK

Responsible Party

Task

Timeline

Verification Method

distribute them widely

Department

handouts

Train staff on how to complete and submit grievance forms Acknowledge all grievances within 24 hours via automated system Enter every grievance into the Central Grievance Log (CGL) Initiate preliminary investigation within 1 hour for urgent cases Conduct a thorough Root Cause Analysis (RCA) on each incident Develop and implement a Corrective Action Plan (CAP) Communicate corrective actions to the complainant and involved staff Monitor the effectiveness of corrective actions Close the grievance and update the CGL after successful resolution Process any appeals within 30 days of appeal submission Compile quarterly reports on grievance trends and corrective actions

Training Department / HR

During orientation and annually

Training attendance records, assessments

Grievance Coordinator

Immediately (within 24 hours)

Automated email confirmations, log entries

Grievance Coordinator / IT

Immediately upon submission

CGL review and audit trail logs

Supervisors / Incident Response Team Assigned Investigator / QA Team

Immediately for urgent cases, 24 hours for others

Incident logs, initial investigation reports

Within 24 – 48 hours

RCA documentation, meeting minutes

QI Committee / Department Heads

Within 72 hours

Written CAP with timelines and assigned responsibilities Email notifications, updated IRF notes, CAP records Follow-up reports, feedback surveys, dashboard alerts CGL updated status, final incident report Appeal decision letter, updated CGL, final notes QI reports, digital dashboards, external audit reports

Grievance Coordinator

As soon as CAP is approved

QA Team / Grievance Coordinator

Ongoing (daily/weekly)

Grievance Coordinator / QA Team

Within 1 week of resolution

Appeals Review Committee

Within 30 days post-appeal

QA Team / Compliance

Quarterly