To implement a coordinated effort in monitoring and evaluating the effectiveness of our institution-wide laboratory policies and procedures with respect to quality of service by:

  • Identifying and correcting problem

  • Assuring the accurate, reliable reporting of test results

  • Preventing the occurrence of future errors

  • Providing the best possible service for out-patients.

This procedure focuses on the steps involved with responding to complaints through thorough investigation and resolution of problems that affect quality of care.


1. Unless the complaint is directed to a specific individual (such as Medical Director) the manager of the appropriate section should respond.

2. In cases where the complaint is directed to someone other than the manager, the manager should still be an active participant in gathering information to respond.

3. Verbal complaints received during second or third shift should be directed to the Tech-In-Charge (TIC). The TIC should document the complaint in the Tech-In-Charge log book and do what he or she can to correct the problem.

4. The TIC should report the complaint, along with corresponding documentation, to his or her manager during the morning shift change.

5. The manager should reply to the person complaining as soon as all necessary information has been obtained and an understanding of the problem determined.

6. The manager should not use a form letter, blame a specific individual, hide behind policy, or be condescending or patronizing.


1. Start with an apology to deflate anger, if an apology is indicated, but avoid culpability statements. For example, "I’m sorry that you had problem with our service" is better than "I’m sorry that our transcriptionist failed to fax the report to you".

2. If a danger exists of legal action against UAMS or one of its personnel, turn the complaint over to the Administrative Director for coordination with Risk Management.

3. Verbal complaints should be responded to verbally within 24 hours of receiving the initial complaint. A written follow up may or may not be necessary, depending on the circumstance. The complaint, however, should be documented using the Quality Assurance Follow Up Request form.

4. A written complaint should be followed up with a written response. A verbal response to the written complaint should be made within 24 hours of receiving the initial complaint/document.

5. The verbal acknowledgment should communicate that a written response will be forthcoming as soon as all information is gathered.


1. Every complaint is a potential quality assurance audit: there are objectives, data, analyses, and resolutions.

2. The Department may receive complaints either verbally, by email, by letter or memo, or by use of the variance form. Regardless of the method of receipt, all laboratory personnel working through a complaint must use the Quality Assurance Variance Report form.

3. Once initiated, a copy of the Quality Assurance Variance Report form must be forwarded to the Performance Improvement (PI) Manager or Administrative Director.

4. The PI Manager or Administrative Director will log the complaint as ‘pending’ in a variance report book.

5. A control number will be assigned that consists of the year followed by a sequential number.

6. All complaints will be summarized and presented as part of the Laboratory’s Performance Improvement.

7.  All complaints will be reviewed at time of receipt to determine if a UHC Variance should be filed.  Determination of forwarding variances to entities outside the Department is made in consultation with the section manager, the PI Manager and the Administrative Director.


**Policy review dates and signatures are available and on file in the laboratory.


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