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Clinic: 507.642.5200
Urgent Care: 507.642.3255
Hospital: 507.642.3255
121 Drew Ave SE, Madelia, MN 56062

Reporting Patient Safety Care Concerns

or Quality of Care Concerns 

Form to report a Patient Safety Event

The mission of the Madelia Community Hospital & Clinic (MCHC) is to provide safe and quality health services to those we serve in an environment based on respect, dignity, and excellence. Because patient safety and quality of care are a part of our mission, we welcome all reports about the safety or quality of care provided at MCHC as an opportunity for improvement. Therefore, it is the policy of this hospital to encourage anyone with concerns to report them. If the concern has not been resolved satisfactorily, the person is encouraged to contact The Joint Commission.

Reporting Procedures: 

It is preferable to receive a report of concern for patient safety or quality of care in writing. A phone call will also be accepted.

Complete this form and submit to the Quality/Risk Management Director (Jodi Ulmen) for review and investigation as needed. OR

Phone calls may be made to:

Roz Snyder, Chief Clinical Officer:  507.642.3255

Jodi Ulmen, Quality/Risk Management Director:  507.642.5226

The person receiving the report will respond to the known submitter the findings and action plan. 

If the concern has not been resolved satisfactorily by MCHC, the person is encouraged to file a written patient safety report with The Joint Commission

At www.jointcommission.org, using the “Report a Patient Safety Event” link in the “Action Center” on the home page of the website 

By fax to 630.792.5636

By mail to Office of Quality and Patient Safety, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181 

Reports of patient safety concerns to The Joint Commission must include the health care organization’s name, street address, city and state. In the course of evaluating a report, The Joint Commission may share the information with the organization that is the subject of the report. Joint Commission policy forbids accredited organizations from taking retaliatory action against employees for having reported quality-of-care concerns to The Joint Commission.

Those who submit a patient safety concern to The Joint Commission can do so anonymously. As an alternative, they can confidentially provide their name and contact information. This enables The Joint Commission to contact them at a later time for more information if necessary and to confirm how the report is handled.