Monthly Report Template
The report the whole cycle runs on: register, themes, praise, cases with the facility's response, action log. With a complete worked example month
Foreword
1. Part A — The Template
A1 Cover
A2 The month in numbers
A3 Themes
A4 Praise
A5 Cases and the facility's response
A6 Action log
2. Part B — Worked Example: March 2026, Central District Hospital (120 beds)
B1 Cover
B2 Numbers
B3 Themes
B4 Praise
B5 Cases
B6 Action log
B7 The meeting that followed
Annex A — Register Format (spreadsheet columns)
References
Index
Foreword
The report is the council's memory and its agenda. It is written by the secretariat on the last working day of every month, sent to the facility for verification, and then to the members 48 hours before the meeting. It has six parts, always in the same order, so that months are comparable and nobody has to hunt for anything. Part A of this document is the template with instructions; Part B is a complete example month from a fictional 120-bed hospital.
1. Part A — The Template
A1 Cover
| Facility | |
|---|---|
| Month | |
| Report number | PV-[facility code]-[YYYY-MM] |
| Prepared by (secretariat) | |
| Draft sent to facility | date |
| Facility response received | date |
| Sent to council | date |
| Meeting date |
A2 The month in numbers
| Measure | This month | Last month | 3-month average |
|---|---|---|---|
| Items received | |||
| — concerns | |||
| — praise | |||
| — questions and ideas | |||
| By channel: QR · hotline · form · email · paper · social | |||
| Anonymous | |||
| Severity 3 or 4 | |||
| Acknowledged within 2 working days (%) | |||
| Loop closed within 5 working days of meeting (%) | |||
| Open actions carried forward |
A3 Themes
One line per theme with the count and the trend arrow. Themes come from Annex A of the Terms of Reference (clinical · management · relationships).
| Theme | Count | Trend | One-line note |
A4 Praise
By name of the staff member praised, with the ward and the patient's words (with consent). Praise is passed to the ward manager for the staff board before the meeting.
| Staff member | Ward / service | Patient's words | Passed on (date) |
A5 Cases and the facility's response
One block per case. The facility completes the shaded column. Nothing in the white columns is changed by the facility.
| Case no. | Channel · date | What the patient said (verbatim or close) | Theme · severity | Facility response (found · done · date) | Status |
A6 Action log
Carried from meeting to meeting until closed.
| No. | Action | Owner | Due | Status | Closed on |
2. Part B — Worked Example: March 2026, Central District Hospital (120 beds)
All names and facts are fictional.
B1 Cover
| Facility | Central District Hospital, Kutaisi |
| Month | March 2026 |
| Report number | PV-CDH-2026-03 |
| Prepared by | A. Beridze, ASF secretariat |
| Draft sent to facility | 1 April 2026 |
| Facility response received | 6 April 2026 |
| Sent to council | 7 April 2026 |
| Meeting date | 9 April 2026, 17:30 |
B2 Numbers
| Measure | March | February | 3-month avg |
|---|---|---|---|
| Items received | 31 | 24 | 26 |
| — concerns | 22 | 18 | 19 |
| — praise | 7 | 4 | 5 |
| — questions and ideas | 2 | 2 | 2 |
| By channel | QR 14 · hotline 6 · form 5 · paper 4 · social 2 | QR 11 · hotline 5 · form 4 · paper 3 · social 1 | — |
| Anonymous | 9 (29%) | 7 | 8 |
| Severity 3 or 4 | 1 (sev. 3) | 0 | 0.3 |
| Acknowledged within 2 working days | 100% | 96% | 98% |
| Loop closed within 5 working days | — (this meeting) | 100% | 100% |
| Open actions carried forward | 3 | 4 | — |
B3 Themes
| Theme | Count | Trend | Note |
|---|---|---|---|
| Discharge and transfer — waiting | 9 | ↑ from 3 | Cluster 12–14 March |
| Environment — night-time noise | 5 | → | Ward 2 and Ward 4 |
| Communication — not told what to expect | 4 | ↓ from 6 | |
| Medication — timing | 1 | new | Severity 3 |
| Finance — invoice unclear | 2 | → | |
| Waiting — outpatient cardiology | 1 | ↓ |
B4 Praise
| Staff member | Ward / service | Patient's words | Passed on |
|---|---|---|---|
| Nino Kapanadze, nurse | Ward 3 | "She explained every tablet and came back to check. Four separate patients said so." | 3 April |
| Dr. L. Gogia | Emergency | "Calm, clear, and he called my daughter himself." | 3 April |
| Reception team, morning shift | Reception | "Fast and kind, even at 7 a.m." | 3 April |
B5 Cases (selection of 5 of 22)
| Case | Channel · date | What the patient said | Theme · sev. | Facility response | Status |
|---|---|---|---|---|---|
| PV-CDH-2026-03-004 | QR · 13 Mar | Waited from 10:00 to 16:20 for discharge papers; nobody could say why. | Discharge · 2 | Pharmacy dispensing system down 12–14 March; discharge letters delayed hospital-wide. System restored 15 March; manual fallback procedure now written. Apology offered. | Answer ready |
| PV-CDH-2026-03-009 | Hotline · 17 Mar (anonymous) | Evening antibiotic given at 23:40 instead of 20:00; nurse said "handover was late". | Medication · 3 | Confirmed from the drug chart. Handover on Ward 4 ran 90 minutes late that evening. Written handover-time rule and a second medication round check to be in place by 30 April. | Action 03-A |
| PV-CDH-2026-03-012 | Paper · 19 Mar | Construction noise all night, could not sleep two nights running. | Environment · 1 | Disputed: no works inside the hospital that week; municipal road works outside Ward 4 on 18–19 March. Hospital has written to the municipality. Earplugs now offered on Ward 4. | Answer ready (disputed, both versions shown) |
| PV-CDH-2026-03-015 | Form · 22 Mar | Was not told the scan would need fasting; came, was sent home, lost a day's work. | Communication · 2 | Appointment SMS did not include preparation instructions. Template amended 25 March. | Answer ready |
| PV-CDH-2026-03-021 | Social · 28 Mar | Public Facebook post: invoice shows a "consumables" line with no detail. | Finance · 1 | Itemised invoice issued to the patient 30 March; finance to itemise consumables on all invoices from May. | Action 03-B |
B6 Action log
| No. | Action | Owner | Due | Status | Closed |
|---|---|---|---|---|---|
| 02-C | Signage to outpatient cardiology in Georgian and English | Head of admin | 31 Mar | Closed | 28 Mar |
| 02-D | Discharge-time data reported monthly for three months | Head of quality | Monthly | Ongoing (1 of 3) | |
| 03-A | Written handover-time rule; second medication round check, Ward 4 | Nursing director | 30 Apr | Open | |
| 03-B | Itemised consumables on all invoices | Finance manager | 31 May | Open | |
| 03-C | Preparation instructions in all appointment SMS templates | Head of admin | 30 Apr | Open |
B7 The meeting that followed
9 April, 17:30–19:00. Present: 6 members (chair: T. Kvirikashvili), head of quality, head of administration, nursing director (for case 009), secretariat. The council asked that discharge-time data continue for three months and that the handover rule be shared with the council when written. Praise passed to the staff board. 22 letters sent 14 April. Education session: "Questions to ask before you are discharged", 11 attendees. Record published 15 April.
Annex A — Register Format (spreadsheet columns)
The secretariat keeps one register, one row per item. Columns:
| Column | Content |
|---|---|
| Case no. | PV-[code]-[YYYY-MM]-[nnn] |
| Received | Date and time |
| Channel | QR · hotline · form · email · paper · WhatsApp · social |
| Type | Concern · praise · question · idea |
| Anonymous | Yes / No |
| Contact (if given) | Held by secretariat only |
| Ward / service | |
| Text | Verbatim |
| Theme | From taxonomy |
| Severity | 1–4 |
| Acknowledged | Date |
| Facility response | Text and date |
| Council decision / action no. | |
| Loop-closure letter sent | Date and template used |
| Status | Open · answered · closed |
References
- Gillespie A, Reader TW. The Healthcare Complaints Analysis Tool. BMJ Qual Saf. 2016;25(12):937–946.
- Accréditation Sans Frontières. Patient Voice Council — Terms of Reference and Method Guide, ASF-PV-TOR-001-v1. Paris: ASF; 2026.
Index
Action log, A6, B6
Cover, A1
Disputed cases, B5 (case 012)
Facility response column, A5
Praise, A4, B4
Register, Annex A
Themes, A3, B3
Worked example, Part B
| Document Title | Patient Voice — Monthly Report Template |
| Document Reference | ASF-PV-REPORT-001-v1 |
| Version / Edition | Version 1 |
| Status | Published |
| Date of Publication | 13 September 2026 |
| Place of Publication | Paris, France |
| Issuing Authority | ASF International Standards Council, Accréditation Sans Frontières |
| Language of Origin | English |
| Effective Date | 13 September 2026 |
| Next Scheduled Review | 13 September 2028 |
| Supersedes | None — first edition |
Foreword1. Part A — The TemplateA1 CoverA2 The month in numbersA3 ThemesA4 PraiseA5 Cases and the facility's responseA6 Action log2. Part B — Worked Example: March 2026, Central District Hospital (120 beds)B1 CoverB2 NumbersB3 ThemesB4 PraiseB5 Cases (selection of 5 of 22)B6 Action logB7 The meeting that followedAnnex A — Register Format (spreadsheet columns)ReferencesIndex
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