Memorial Hospital for Children, as a part of Memorial Health System, endeavors to meet its patients' expectations for care and services in a timely, reasonable and consistent manner. Patients (or their immediate family or personal representatives) have the right to submit a complaint, verbally or in writing, 24 hours per day. Memorial Health System, 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 Health System 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 Health staff under Step 1, or if a patient submits a written complaint, the Memorial Health System staff member will forward the complaint to the Memorial Health System Patient Representative by the next working day. Patients may also file a grievance, verbally or in writing, 24 hours per day by contacting the Patient Representative through at (719) 365-5621. The Patient Representative will contact the patient within three (3) working days of receipt of the grievance to acknowledge receipt of 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.

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 Health System 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

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 Health System 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
• Email: complaint@jointcommission.org
• Fax: 1-630-792-5636
• Website: http://www.jointcommission.org/GeneralPublic/Complaint/
• 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 Health System 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.