Patient Voice Council — Terms of Reference and Method Guide
One council, one meeting a month, seven steps. How an independent patient council is set up and run, with worked examples
Foreword
1. Purpose and Scope
1.1 Purpose
1.2 What the council is not
1.3 Where it applies
2. Membership
2.1 Composition
2.2 Size
2.3 Eligibility
2.4 The chair
2.5 Hospital representatives
2.6 The secretariat
2.7 Term and attendance
3. Recruitment
3.1 Who recruits
3.2 Where
3.3 How to apply
3.4 Selection
4. The Monthly Cycle — Seven Steps
4.1 Collect
4.2 Report
4.3 Verify with the facility
4.4 Council meeting, part one
4.5 Close the loop
4.6 Council meeting, part two — education
4.7 Publish
5. Communication Between Meetings
5.1 The WhatsApp group
5.2 What goes in it and what does not
5.3 Individual cases
6. Confidentiality, Conduct and Independence
6.1 The three agreements
6.2 Anonymity
6.3 Public statements
6.4 Conflicts of interest
7. The Secretariat's Craft
7.1 Precision
7.2 Persistence
7.3 Interest
7.4 The monthly test
8. Records and Reporting
8.1 What is kept
8.2 What is published
8.3 Retention
9. Adapting This Method
9.1 Small clinics
9.2 Large hospitals
9.3 Outside Georgia
Annex A — Feedback Taxonomy (themes and severity)
Annex B — Agenda Template (90 minutes)
Annex C — Adopting Organization Checklist
References
Index
Foreword
Every hospital has a feedback form, and every hospital knows what happens to it. Patients fill it in carefully, because the hospital that treated them will read it and they may need that hospital again. The form says everything was fine. The truth goes to Facebook.
The Patient Voice council exists to move the truth from social media back into a room where it can be acted on. It is deliberately simple: a small council of patients, one or two people from the hospital, and a neutral secretariat that is not the hospital. It meets once a month for sixty to ninety minutes. It is built on a report of everything patients said in the previous month, verified with the hospital before anyone sits down, and it ends every cycle by answering each patient in writing.
This document is the complete method. It has been run in Georgian hospitals since January 2024, in a health system with no prior tradition of independent patient voice. It is written so that any organization — a hospital, a national body, an NGO — can set up its own council from this text alone, with the four companion documents in the Patient Voice Toolkit.
1. Purpose and Scope
1.1 Purpose
The council gives patients and families a structured, independent, monthly channel to be heard by the facility that treats them; gives the facility verified, themed, actionable feedback every month; and closes the loop with every person who raised a concern, so that the concern is answered before it becomes a public one.
1.2 What the council is not
It is not a complaints tribunal. It does not adjudicate individual cases or award remedies.
It is not a disciplinary body. It has no authority over any member of staff.
It is not a hospital committee. The hospital sits at the table; it does not run the table.
It is not an advocacy group. The secretariat takes neither side.
1.3 Where it applies
Any healthcare facility: hospital, ambulatory clinic, dental practice, long-term care home, primary care centre. Accreditation by ASF is not required; membership of ASF is not required. The facility need only agree to the Facility Participation Agreement (ASF-PV-FACILITY-001).
2. Membership
2.1 Composition
| Seat | Number | Selected by | Role |
|---|---|---|---|
| Patient and family members | 3 to 6 (never more than 7) | Open, continuous recruitment (Section 3) | The council. Review the report, ask, propose, decide what to raise |
| Chair | 1, from among the patient members | Elected by the members | Chairs the meeting; signs the record; rotates yearly |
| Hospital representatives | 1 or 2 | The facility | Explain what was found and done; take actions away |
| Secretariat | 1 | ASF (or the adopting organization) | Collects, reports, verifies, convenes, records, tracks, educates, closes the loop |
2.2 Size
Three members is the minimum for a small clinic. Six is the working maximum. Seven is tolerable; eight is not. Beyond six, honest discussion becomes management, quiet members stop speaking, and the meeting stops fitting in ninety minutes.
2.3 Eligibility
Any current or former patient of the facility, or a family member or carer of one, aged 18 or over, who has signed the Council Member Agreement (ASF-PV-MEMBER-001). No employee of the facility, no supplier, and no one holding a financial interest in it may be a patient member. A patient member who becomes an employee steps down.
2.4 The chair
The chair is a patient, elected by the patient members at the first meeting and thereafter whenever the seat falls vacant. The chair serves for no more than twelve months and may not be re-elected consecutively. The chair opens and closes the meeting, keeps it to time with the secretariat, signs the record, and speaks for the council if the council decides anything should be said publicly.
2.5 Hospital representatives
Usually the head of quality and the head of reception or administration — the two people with first contact with patients and the authority to fix most of what they hear. A clinical director may attend when a clinical theme is on the agenda. Hospital representatives do not chair, do not vote, do not set the agenda, and do not receive the identity of any complainant who asked for anonymity.
2.6 The secretariat
One named person. Precise and persistent. The secretariat keeps the feedback register, writes the monthly report, verifies it with the facility, convenes the meeting, records it, tracks every action to closure, runs the education session, and writes to every patient who raised a concern. The secretariat is bound by the Secretariat Impartiality Undertaking (ASF-PV-SECRETARIAT-001).
2.7 Term and attendance
Members serve without fixed term; the council is designed for people to come after a stay, serve, and move on. A member who misses three consecutive meetings is contacted by the secretariat and asked whether they wish to continue. Membership is voluntary and unpaid; reasonable transport costs may be reimbursed by the facility if the council so agrees.
3. Recruitment
3.1 Who recruits
The facility. Recruitment is open, public and continuous. A council that is hand-picked by management is a focus group; a council recruited by open invitation is a council.
3.2 Where
The facility's website — a permanent page
The facility's social media — a post at launch and a reminder every quarter
The entrance, the reception desk and the patient corner — a printed notice (template in ASF-PV-RECRUIT-001)
Discharge papers — one line with the QR code
3.3 How to apply
By the application form (ASF-PV-RECRUIT-001, Annex B), online or on paper, or by a message to the secretariat. The form asks for name, contact, the relationship to the facility (patient, family member, carer), and one sentence on why the person wants to join. Nothing else.
3.4 Selection
When there are more applicants than seats, the secretariat and the current chair select for diversity of department and experience — an inpatient, an outpatient, a parent, an older person — not for agreeableness. Applicants not selected are kept on a waiting list and invited to the education sessions.
Worked example — a 40-bed district hospital
The hospital posts the notice on Facebook and at reception on 1 March. By 20 March it has nine applicants. The secretariat and the outgoing chair choose six: two former inpatients (surgery, maternity), two outpatients (cardiology, dialysis), one parent of a paediatric patient, one carer of an elderly patient. Three go on the waiting list. The first meeting is on 8 April.
4. The Monthly Cycle — Seven Steps
| Step | When | Owner | Output |
|---|---|---|---|
| 1 Collect | All month | Secretariat | One register, one case number per item |
| 2 Report | Last working day of the month | Secretariat | Draft monthly report |
| 3 Verify | Working days 1–5 | Facility liaison + secretariat | Verified report with facility responses |
| 4 Meeting, part one | Working days 7–10, 40–60 minutes | Chair | Action log with owners and dates |
| 5 Close the loop | Within 5 working days of the meeting | Secretariat | Written answer to every patient |
| 6 Meeting, part two | Same meeting, 30 minutes | Secretariat | Education session record |
| 7 Publish | Within 5 working days of the meeting | Secretariat + chair | Public council record |
4.1 Collect
Every piece of feedback from every source lands with the secretariat, not the facility: the QR code in the wards and on discharge papers, the hotline, the online form, email, paper forms from the patient corner, WhatsApp messages, and social-media posts in which the facility or ASF is mentioned or tagged. Praise is collected as carefully as complaints. Each item receives a case number on receipt and an acknowledgement within two working days.
4.2 Report
On the last working day of the month the secretariat writes the monthly Patient Voice report (template: ASF-PV-REPORT-001). Every case appears, themed and severity-coded with the taxonomy in Annex A; praise appears by name of the staff member praised; each open case shows what was asked and what is still open. Identities of complainants who asked for anonymity do not appear anywhere in the report.
4.3 Verify with the facility
The draft goes to the facility liaison before anyone else sees it. This is the conflict-of-interest safeguard in the other direction: patients sometimes report inaccurately, without context, or about something already fixed. The facility has five working days to clarify, correct facts, and state what has already been done. Its response is entered in the report beside each case. Nothing is removed and nothing is softened; facts are checked.
4.4 Council meeting, part one (40–60 minutes)
The chair opens. The secretariat presents the verified report: the numbers, the themes, the praise, then each open case. For each, the hospital representative says what was found and what has been done. The council discusses: what should be done, by whom, by when — and, most important, whether an answer can now be given to the patient. Decisions go into the action log.
4.5 Close the loop
Within five working days of the meeting, the secretariat writes to every patient who raised a concern that month (templates: ASF-PV-LETTER-001): what you told us, what was found, what changed, who to contact. This is the step that matters most. A person who is heard once rarely complains twice. A person who complains into silence goes where they will be heard, and the second complaint is public, angrier, and aimed at the doctor by name.
4.6 Council meeting, part two — education (30 minutes)
Every meeting ends with one education session on one topic, chosen by the secretariat from what the month's feedback shows patients most need to know (calendar: ASF-PV-EDU-001). Members, the waiting list and, where the facility wishes, other patients are invited. The session is recorded in one paragraph in the council record.
4.7 Publish
The council record — attendance, themes, decisions, actions, education topic, with nothing that identifies a patient — is signed by the chair and published on the facility's ASF profile and, in Georgia, on pacienti.ge. Open actions carry forward to next month's report until closed.
Worked example — one month at a 120-bed hospital
March: 31 items collected — 22 concerns, 7 praise, 2 questions. Themes: waiting at discharge (9), night-time noise (5), a named nurse praised four times (Nino, Ward 3). One concern about a medication given late is coded severity 3 and escalated to the liaison the same day.
2 April: draft report to the liaison. The facility clarifies that discharge delays were caused by a pharmacy system outage on 12–14 March, now fixed, and disputes one noise complaint (construction was outside the building). Both entries are annotated.
9 April, 17:30–19:00: meeting. The council asks for discharge-time data every month for three months. Nino's praise is passed to the ward manager for the staff board. The late-medication case is confirmed as a process gap; the hospital commits to a written handover rule by 30 April.
14 April: 22 letters sent. Education session: "Questions to ask before you are discharged", chosen because of the discharge theme. 11 attendees. Record published 15 April.
5. Communication Between Meetings
5.1 The WhatsApp group
One group: members, hospital representatives, secretariat. Created by the secretariat, who is the only administrator. Used for meeting reminders, sharing the verified report 48 hours before the meeting, sharing education materials, and short questions.
5.2 What goes in it and what does not
| Yes | No |
|---|---|
| Meeting date, place, agenda | Any individual case or patient name |
| The verified monthly report (PDF) | Photographs of patients or records |
| Education materials and links | Debate about a specific staff member |
| A member letting others know they cannot attend | Anything a member would not say in the meeting |
5.3 Individual cases
A member who becomes aware of a new concern sends it to the secretariat directly (hotline, form, or a private message), never to the group. The secretariat registers it as any other case.
6. Confidentiality, Conduct and Independence
6.1 The three agreements
Council Member Agreement (ASF-PV-MEMBER-001) — signed by every patient member.
Secretariat Impartiality Undertaking (ASF-PV-SECRETARIAT-001) — signed by the secretariat for each council.
Facility Participation Agreement (ASF-PV-FACILITY-001) — signed by the facility.
6.2 Anonymity
A patient may ask that their identity not be disclosed to the facility. The secretariat honours this wherever a genuine inquiry is possible without disclosure, and tells the patient plainly when the nature of the concern would identify them regardless. The facility undertakes never to seek an anonymous complainant's identity.
6.3 Public statements
Members do not speak publicly, post, or contact media about council business. If the council decides something should be said publicly, the chair says it, in words the council agreed, and the secretariat records it. This protects the council: a body that leaks is a body no one speaks to.
6.4 Conflicts of interest
Any member with a personal or financial interest in a matter under discussion says so and does not take part in that item. The secretariat records the declaration. The secretariat itself holds no interest in the facility and receives no payment linked to any outcome (ASF Code of Conduct, Principle 4; Independence and Non-Influence Statement).
7. The Secretariat's Craft
A council is easy to start and hard to keep. People are busy, they miss meetings, the novelty fades. The secretariat's whole craft is in three words.
7.1 Precision
The report on time, every month, in the same format, with every case. The meeting starts and ends on time. The letters go out within five working days. Every action has an owner and a date, and is chased until closed.
7.2 Persistence
A member who misses a meeting gets a message the next day — not a reproach, an update and an invitation. A hospital action that slips gets a reminder before the next meeting, not at it.
7.3 Interest
The education session is chosen to be genuinely useful; a good speaker is found; members are invited to bring a guest. The council should be a meeting people look forward to.
7.4 The monthly test
8. Records and Reporting
8.1 What is kept
The feedback register (all cases, all sources, case numbers, dates, status)
The monthly reports and the facility's responses
The action log
Council records, signed by the chair
Copies of loop-closure letters
Signed agreements and declarations of interest
8.2 What is published
The council record (without identifying details), the annual summary (volumes, themes, response times against targets, improvements made), and the education calendar. Individual cases are never published.
8.3 Retention
Case files: three years after closure, then deleted. Council records and annual summaries: permanent. All processing under the ASF Data Protection Policy (ASF-DATAPROTECT-001) and applicable national law.
9. Adapting This Method
9.1 Small clinics
Three members, one hospital representative, a 45-minute meeting, a bi-monthly cycle if volumes are very low. The seven steps do not change.
9.2 Large hospitals
One council per site or per major service line (maternity, oncology) rather than one large council. Each keeps to six members. A quarterly joint session of chairs and the hospital board replaces the cross-council reporting line.
9.3 Outside Georgia
Translate the four toolkit documents; attach the local-law annex to the agreements; choose the local public archive; decide the hotline hours in local time. Keep the seven steps, the size limits, the chair rotation and the loop-closure deadline unchanged — they are the method.
Annex A — Feedback Taxonomy (themes and severity)
Themes are adapted from the Healthcare Complaints Analysis Tool (Gillespie & Reader, 2016); severity is coded 1–4.
| Domain | Themes | Examples |
|---|---|---|
| Clinical | Quality of care · Safety incidents · Medication · Diagnosis and treatment decisions | A dose given late; a wrong-side mark; a missed allergy |
| Management | Environment · Waiting and access · Discharge and transfer · Bureaucracy · Finance and billing | Discharge delayed six hours; unclear invoice; no parking for disabled patients |
| Relationships | Communication · Respect and dignity · Confidentiality · Patient rights and consent | Not told what the procedure involved; spoken to rudely; results discussed in a corridor |
| Severity | Meaning | Handling |
|---|---|---|
| 1 — Minor | Inconvenience, no harm | Monthly cycle |
| 2 — Moderate | Distress or delay, no lasting harm | Monthly cycle; liaison informed at report |
| 3 — Serious | Harm, or a clear risk of harm | Liaison informed within one working day; monthly cycle |
| 4 — Immediate danger | Ongoing risk to a patient now | Escalated the same day under the ASF Sentinel Event Policy; not queued |
Annex B — Agenda Template (90 minutes)
| Time | Item | Lead |
|---|---|---|
| 0:00 | Welcome, attendance, declarations of interest | Chair |
| 0:05 | Actions from last month — status | Secretariat |
| 0:15 | The month in numbers and themes | Secretariat |
| 0:20 | Praise — passed to staff | Secretariat / hospital |
| 0:25 | Open cases — what was found, what was done, what next | Hospital representative, council |
| 0:50 | Decisions and action log | Chair |
| 0:58 | Which patients can be answered now | Secretariat |
| 1:00 | Education session | Secretariat / guest |
| 1:28 | Next meeting date; close | Chair |
Annex C — Adopting Organization Checklist
An organization other than ASF may run the method as secretariat if it meets all of the following:
☐ Legally independent of the facility; no ownership, governance, employment or supplier relationship
☐ Signs the Secretariat Impartiality Undertaking for each council
☐ Names one person as secretariat, with a deputy
☐ Uses the four toolkit documents, adapted and attributed
☐ Publishes the council record within five working days of each meeting
☐ Reports annually to ASF on volumes, response times and improvements, for the shared evidence base
ASF provides the toolkit, training for the secretariat, and — where asked — a review of the first three council records. Contact: info@accreditation.ge.
References
- Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf. 2014;23(8):678–689.
- Gillespie A, Reader TW. The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning. BMJ Qual Saf. 2016;25(12):937–946.
- Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002;287(22):2951–2957.
- Parliamentary and Health Service Ombudsman. NHS Complaint Standards. London: PHSO; 2021, in force from April 2023.
- Australian Commission on Safety and Quality in Health Care. Australian Charter of Healthcare Rights, 2nd ed. Sydney: ACSQHC; 2019.
- Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards, 2nd ed. — Partnering with Consumers Standard. Sydney: ACSQHC; 2021.
- International Ombuds Association. Standards of Practice, v. 2022. IOA; 2022.
- Accréditation Sans Frontières. Public Complaints and Feedback Policy, ASF-COMPLAINTS-001-v2. Paris: ASF; 2026.
- Accréditation Sans Frontières. Sentinel Event Policy, ASF-SEP-001-v1. Paris: ASF; 2026.
- Accréditation Sans Frontières. Code of Conduct, ASF-CONDUCT-001-v2. Paris: ASF; 2026.
- Accréditation Sans Frontières. Data Protection Policy, ASF-DATAPROTECT-001-v1. Paris: ASF; 2026.
Index
Anonymity, 6.2
Agenda, Annex B
Chair, 2.4
Close the loop, 4.5
Education session, 4.6
Hospital representatives, 2.5
Loop-closure letter, 4.5
Monthly test, 7.4
Recruitment, 3
Report, monthly, 4.2
Secretariat, 2.6, 7
Severity coding, Annex A
Size of council, 2.2
Taxonomy, Annex A
Verify with the facility, 4.3
WhatsApp group, 5
| Document Title | Patient Voice Council — Terms of Reference and Method Guide |
| Document Reference | ASF-PV-TOR-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. Purpose and Scope1.1 Purpose1.2 What the council is not1.3 Where it applies2. Membership2.1 Composition2.2 Size2.3 Eligibility2.4 The chair2.5 Hospital representatives2.6 The secretariat2.7 Term and attendance3. Recruitment3.1 Who recruits3.2 Where3.3 How to apply3.4 Selection4. The Monthly Cycle — Seven Steps4.1 Collect4.2 Report4.3 Verify with the facility4.4 Council meeting, part one (40–60 minutes)4.5 Close the loop4.6 Council meeting, part two — education (30 minutes)4.7 Publish5. Communication Between Meetings5.1 The WhatsApp group5.2 What goes in it and what does not5.3 Individual cases6. Confidentiality, Conduct and Independence6.1 The three agreements6.2 Anonymity6.3 Public statements6.4 Conflicts of interest7. The Secretariat's Craft7.1 Precision7.2 Persistence7.3 Interest7.4 The monthly test8. Records and Reporting8.1 What is kept8.2 What is published8.3 Retention9. Adapting This Method9.1 Small clinics9.2 Large hospitals9.3 Outside GeorgiaAnnex A — Feedback Taxonomy (themes and severity)Annex B — Agenda Template (90 minutes)Annex C — Adopting Organization ChecklistReferencesIndex
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