I.-The Commission ensures that users’ rights are respected and facilitates their procedures.
To this end, all complaints and claims addressed to the health care institution by users or their relatives, as well as the responses given to them by the institution’s managers, are made available to the members of the Commission, in accordance with the procedures defined by the institution’s internal regulations. Under the conditions laid down in articles R. 1112-93 and R. 1112-94, the Commission examines those complaints and claims which do not constitute an informal or legal appeal and ensures that all persons are informed of the means of appeal and conciliation available to them.
II – Through its opinions and proposals, the Commission helps to improve the policy for receiving and caring for patients and their families. To this end :
1° It receives all the information it needs to carry out its duties, in particular :
a) The measures relating to the policy of continuous quality improvement prepared by the establishment’s medical commission in accordance with 3° of article L. 6144-1 , as well as the opinions, wishes or recommendations formulated in this field by the establishment’s various consultative bodies;
b) A summary of the claims and complaints addressed to the health care organisation by users or their relatives over the previous twelve months;
c) The number of requests for medical information made under article L. 1112-1 and the time limits within which the health care organisation complies with these requests;
d) The results of surveys concerning the assessment of user satisfaction provided for in article L. 1112-2, in particular the assessments made by patients in discharge questionnaires;
e) The number, nature and outcome of any appeals lodged against the establishment by users;
f) A presentation, at least once a year, of the serious undesirable events mentioned in article L. 1413-14 that have occurred during the previous twelve months, as well as the actions taken by the establishment to remedy them.
g) Information on each serious undesirable event associated with healthcare, at the meeting following transmission to the Director General of the Regional Health Agency of the second part of the form referred to in Article R. 1413-69. This information, sent by the legal representative of the establishment or the person appointed by him for this purpose, includes a summary description of the circumstances of the serious undesirable event, the consequences for the person or persons concerned, the immediate measures taken for these persons, as well as the corrective action plan implemented by the establishment.
h) Comments from voluntary organisations that have signed an agreement with the institution, which it collects at least once a year.
The information mentioned in f and g is provided under conditions which guarantee the anonymity of the patient(s) and professionals concerned. In particular, it does not include the surnames and forenames of patients, their address, their date of birth or the surnames and forenames of the professionals involved in their care.
2° On the basis of this information in particular, the committee :
a) Carries out an assessment of the establishment’s practices with regard to users’ rights and the quality of reception and care, based on an analysis of the origin and reasons for complaints, claims and expressions of satisfaction received in the various departments, as well as the action taken in response to them ;
b) Identifies the measures adopted over the past year by the Board of Directors or the collegiate body that acts in its stead with regard to users’ rights and the quality of care and support, and assesses the impact of their implementation;
c) Makes recommendations, particularly with regard to staff training, designed to improve the reception and quality of care for patients and their relatives and to ensure that users’ rights are respected;
3° The commission reports on its analyses and proposals in the report referred to in Article L. 1112-3.
This report only includes anonymous data. After receiving the opinion of the other consultative bodies concerned, it is forwarded to the Board of Directors or to the collegiate body which acts as the Board, at least fifteen days before the meeting during which the Board deliberates on the institution’s policy with regard to users’ rights and the quality of care and treatment. It is also sent, along with the information listed in 1°, to the regional health agency and the regional conference on health and autonomy.
4° The commission may propose a users’ project, after consulting all the representatives of users of the establishment and representatives of voluntary associations that have signed an agreement with the establishment and work within it.
This project is based on the activity reports drawn up in application of the penultimate paragraph of article L. 1112-3. It expresses the expectations and proposals of users with regard to reception policy, the quality and safety of care and respect for users’ rights. The hospital medical committee or the hospital medical conference contributes to its preparation. It is forwarded by the users’ commission to the establishment’s legal representative.
The users’ project is proposed by the users’ commission with a view to drawing up the establishment project for public health establishments, the medical policy for private health establishments or the institutional project for private health establishments of collective interest.
Any analysis, report, proposal or communication produced by the commission and relating to complaints, claims and serious undesirable events guarantees respect for the anonymity of the patient and the professional concerned.