Health Facilities Review Committee

Common questions about the HFRC

1. What does the HFRC do?
2. Where does the HFRC visit?
3. Who serves on the HFRC?
4. Where does the HFRC send reports?
5. How are routine reviews handled?
6. What should you do if you have a complaint?
7. What kinds of complaints can be filed?
8. How is a complaint investigation conducted?
9. How long does it take to complete an investigation?
10. Who receives a copy of the complaint investigation report?
11. What happens after a routine review or complaint investigation report is sent out?
12. How do I file a complaint?
13. Contact the Health Facilities Review Committee

1. What does the HFRC do?

The HFRC monitors the quality of care, treatment and standards of accommodation provided to patients and residents in health-care facilities.

Through the course of their work, HFRC members look for the following:

• Care and treatment of patients or residents that respects both their privacy and dignity;
• Opportunities that permit well-informed and independent choices;
• Accommodation that is comfortable, clean and safe;
• Professional and support staff who are caring and accessible;
• Diagnostic and therapeutic services as well as rehabilitative and recreational programs that are accessible to patients and residents; and
• Volunteer and community groups who are involved and provide support.

2. Where does the HFRC visit?

The HFRC reviews all facilities that operate under the Hospitals Act, the Nursing Homes Act or the Regional Health Authorities Act.

3. Who serves on the HFRC?

The HFRC can have up to 12 members. Members are appointed to the HFRC by the Minister of Health. They come from rural and urban communities throughout the province, and have varied backgrounds, areas of expertise and work experiences. HFRC members represent Albertans – the health-care consumers.

• Members serve on the HFRC on a part-time basis, and are not employees of the provincial government.

4. Where does the HFRC send reports?

HFRC members meet on a monthly basis throughout the year. At monthly meetings, HFRC members discuss and report on all routine reviews and complaint investigations.

After the HFRC has discussed and approved the routine review or complaint investigation reports and recommendations, it sends a copy of the written report to the President and CEO of Alberta Health Services. If the facility is privately owned or operated, the HFRC sends a joint letter to Alberta Health Services and the owner or senior representative of the non-profit or private organization which operates the facility. A copy of the reports is also sent to the chair of the Alberta Health Services Board, the administrator of the facility, and the Minister of Health.

If visiting members have identified a major concern at a facility, the HFRC will bring it to the attention of the Minister of Health. The HFRC also prepares an annual report which is tabled in the Legislative Assembly of Alberta.

5. How are routine reviews handled?

HFRC members usually work in teams of two to four members, depending on the size of the facility. Visiting members spend one to four days at each facility. The HFRC’s routine reviews are not announced in advance. This enables visiting members to observe the facility under normal operating circumstances.

Upon arrival at a facility, HFRC members meet with senior management to outline the nature of the review and gather general information. HFRC members then conduct random interviews with patients, residents, family members, visitors and staff. They ask about programs and services that directly affect the care and satisfaction of patients or residents. They also conduct personal observations of the premises and of the care provided by staff.

Prior to leaving the facility at the end of the routine review, HFRC members provide a verbal report of their general findings to senior management.

6. What should you do if you have a complaint?

If you are a patient, resident or family member, you are encouraged to discuss your suggestions, questions or concerns regarding care, treatment, services or accommodation directly with staff at the facility.

• Begin by discussing issues directly with the member of the care team who is most closely involved with your specific concern. This may be a registered nurse, doctor, dietician, physiotherapist or another member of the care team.
• If needed, contact the supervisor of the nursing unit or director of the department.
• Finally, report your concerns, in writing, to the administrator or owner of the facility or the Patient Concerns Department of Alberta Health Services.

If you feel the problem cannot be resolved at the facility or by Alberta Health Services, you may contact the Health Facilities Review Committee. The Health Facilities Review Committee can only investigate complaints that are made by, or on behalf of, a specific patient or resident in a health-care facility. The HFRC accepts complaints in writing, over the phone, or in person.

The following forms must be completed, signed and returned to the Alberta Health Facilities Review Committee before the HFRC can deal with your concerns:

• Complaint Form – All persons submitting a complaint will be asked to sign a complaint form.
• Authorization to Disclose Health Information Form – Must be completed and signed by the patient/resident or the person authorized to act on the patient/resident’s behalf (e.g., legal guardian, attorney authorized to make medical decisions for the patient under a valid Power of Attorney, personal representative, or anyone with written authorization from the patient to act on his or her behalf). This authorization permits the HFRC to access health information and any other records of the patient/resident in order to investigate the complaint, and to discuss the patient/resident’s care and treatment with staff at the facility. Please note that if the authorization is signed by someone other than the patient/resident, documentation will be required indicating that person’s authority to consent on the patient/resident’s behalf (if other than parent of a minor).

Important: Please note that being the spouse or family member of a patient is not sufficient to provide authorization to disclose health information on a patient’s behalf. The person authorized to act on a patient’s behalf must have legal and/or written (and witnessed) authorization from the patient to act on their behalf. Documented proof of the written authorization will be required.

Upon receipt of the completed forms, the concerns will be reviewed and a decision made as to whether the concerns are within the HFRC’s mandate. All members of the HFRC swear an “Oath of Confidentiality” so that any personal or health information they receive is held in confidence.

7. What kinds of complaints can be filed?

Complaints may be filed about any aspect of patient/resident care, safety or satisfaction. Examples of complaints that can be investigated include:

• Care concerns – response of facility staff, patient monitoring issues, the use of restraint devices or medication administration.
• Safety issues related to building maintenance, cleaning products, fire drills and other matters.
• Concerns regarding satisfaction related to care provided, food, or availability of care and services.

The HFRC cannot investigate complaints about a physician’s professional conduct or medical decisions, or about the conduct of professionals such as nurses. These professionals are regulated through legislation by their own professional associations.

All complaints regarding abuse must be reported to Protection for Persons in Care. The Health Facilities Review Committee does not investigate complaints that relate to abuse of a patient or resident. To report abuse in a care facility or to obtain more information, call (toll-free) 1-888-357-9339.

8. How is a complaint investigation conducted?

Once the HFRC has reviewed a complaint and determined that the concerns fall within the HFRC’s legislated mandate, the complaint investigation process is started. A team of HFRC members is assigned to investigate the complaint.

Investigating members will start the investigation by scheduling a meeting with the complainant and/or the patient or resident. Members will then conduct interviews with witnesses, staff at the facility and anyone else who may have direct knowledge about the circumstances surrounding the complaint. Investigating members will also review the patient or resident’s personal health information records and other relevant documentation, and will gather information based on observations made at the facility.

Through the HFRC’s legislation, HFRC members may enter a facility at any reasonable hour to conduct an investigation, and can request the production of any records of the hospital as described in Section 10 of the Health Facilities Review Committee Act. The HFRC can access records containing individually identifying health information with the patient/resident’s or their guardian’s written consent. The HFRC cannot compel staff members to participate in interviews. However, most staff members willingly and voluntarily co-operate with the investigation.

9. How long does it take to complete an investigation?

The HFRC cannot predict how long an investigation will take. The process is dependent on the availability of information, the ability to conduct interviews and obtain records, and the complexity of the complaint. Once HFRC members feel they have as much supporting evidence as possible, a report is prepared based on their findings. If the HFRC identifies areas that need improvement, recommendations are made to that effect. Although the HFRC cannot force compliance with the recommendations, there has been a high level of voluntary compliance experienced to date.

10. Who receives a copy of the complaint investigation report?

Once the complaint investigation report and any recommendations have been approved by the entire HFRC, the HFRC sends the report to the complainant, the President and CEO of Alberta Health Services and the owner/operator of the facility. A copy of the report is also sent to the Minister of Health, the chair of the Alberta Health Services Board, and the administrator of the facility.

11. What happens after a routine review or complaint investigation report is sent out?

Alberta Health Services and/or the owner/administrator of the facility are asked to respond in writing to the HFRC’s recommendations within 90 days, indicating what actions they have undertaken to address the HFRC’s recommendations and the results they expect to achieve.

The HFRC reviews all responses received at each monthly meeting. If the response received is not satisfactory, the HFRC will follow-up with further correspondence providing additional information and requesting further action, or it may initiate an unannounced visit to the facility.

12. How do I file a complaint?

If you wish to file a complaint, you may download the Complaint Form and Authorization to Disclose Health Information Form . Print the forms, fill them out and either fax or mail them to our office. If you fax the forms to the office, we ask that you send the original documents by mail.

Contact HFRC

Health Facilities Review Committee
First Edmonton Place
590, 10665 Jasper Avenue NW
Edmonton, AB T5J 3S9
Telephone: 780-427-4924
Fax: 780-427-0806

More HFRC information

• Health Facilities Review Committee Act
• Alberta Health Facilities Review Committee Annual Reports