Sutter Health Ombuds Team Frequently Asked Questions (FAQs)

The following information is designed to inform you about Sutter Health’s Ombuds Team.

1. What is the ombuds resource?

The Sutter Health ombuds resource provides physicians and physician assistants with an independent, confidential, impartial, and informal resource that helps effectively manage, address, and surface concerns at work. This resource is provided by an external third-party team of skilled and professional ombuds who will listen and help physicians and physician assistants think through possible solutions to challenges at work. Information about the Sutter Health’s Ombuds Team can be found here.

2. What are the hallmarks of the Sutter Health Ombuds Team?

The Sutter Health Ombuds Team is:

Independent. The ombuds team is a separate entity staffed by a team based outside of the Sutter Health.
Confidential. The ombuds team will keep physicians and physician assistants identities private unless they are given permission to share or if they determine there is an imminent risk of serious physical harm.
Impartial. The ombuds team does advocate for any physicians, physician assistants, medical group presidents, or Sutter Health.
Informal. There are no preconditions to talk with a member of the ombuds team. Each step in the process will be decided by the physicians and physician assistants using the ombuds team. The ombuds team does not participate in any formal processes like grievances, investigations, lawsuits, etc.

3. What do the ombuds team do?

The ombuds team works with “visitors” (i.e., those who reach out to the ombuds team) by listening to their concerns, providing suggestions on addressing interpersonal challenges, and giving unbiased feedback and clarity on dealing with a sensitive topic. The ombuds team can help visitors resolve their own issues informally or help them understand and navigate formal reporting options.

4. What might you gain by contacting the ombuds team?

Insight into a complicated situation; a clearer perspective on an issue or concern; enhanced ability to effectively deal with a problem; identification and clarification of options; an effective communication plan to resolve interpersonal issues; clarity on how to report concerns should you want a resolution of an ongoing problem that is impacting your ability to perform your best ability at Sutter Health.

5. Who can reach out to the ombuds team? How and when can you expect to hear back?

All physicians and physician assistants with a concern related to the work environment are welcome to contact the ombuds team. Generally, the ombuds team will reply within one business day.

6. What does the ombuds team not do?

The services provided by the ombuds team do not replace other roles or procedures at Sutter Health. In addition, the ombuds team does not provide legal advice or psychological counseling and does not render judgments or make decisions on the issues brought to the ombuds. Discussing an issue with the ombuds team does not constitute formal notice to Sutter Health about the existence of a problem. The ombuds team will, however, help physicians and physician assistants find resolution or help the physicians and physician assistants find the proper channels to provide notice (like HR or senior management) about an issue if necessary.

The ombuds team does not advocate for a particular physicians or physician assistants, medical group presidents, or Sutter Health, make binding decisions or mandate policies, participate in claims investigations or other formal resolution processes, nor do they serve as a channel for reporting violations of policy or Sutter Health’s Code of Conduct.

7. When do you reach out to the ombuds team vs. other resources at Sutter Health?

The key distinction is that the ombuds team cannot act as a formal channel for reporting policy or legal violations. To make a formal complaint, physicians and physician assistants should reach out to other organizational resources. The ombuds offers an opportunity to discuss concerns with a resource confidentially and to resolve the issue off-the-record.

8. What are the examples of concerns for which the ombuds team might be able to offer support?

Physicians and physician assistants may find it helpful to engage the ombuds team for information and expert, confidential advice, such as when they:

Experience an interpersonal challenge with a colleague or their manager and need assistance figuring out how to address it or prepare for what could be a difficult conversation
Have a compliance, ethical, legal, or policy concern related to work and want guidance on how to report it to Sutter Health.
Feel uncomfortable about a situation they have experienced and would like advice on whether it’s something they need to report.
Need feedback on, or help in role-playing, how to share a problem or suggestion for improvement with medical group presidents or Sutter Health.
Desire to discuss a concern informally and confidentially, allowing physicians and physician assistants to retain control of the process, consider different perspectives on issues, and have flexibility in crafting resolution.

9. What happens when you contact the ombuds team?

A member of the ombuds team will:

Provide you with enough time and space to share concerns in private
Listen carefully to concerns
Help develop a list of options for resolving a concern, including referring to the appropriate internal resources to resolve issues
Provide answers to questions about where to get more information about a policy or procedure and appropriate work resources for more information
Work with you to prepare or practice giving voice to concerns when participating in difficult conversations or during internal resolution processes.

10. What authority does the ombuds team have?

The ombuds team may contact medical group presidents and Sutter Health about thematic and systemic challenges they learn that physicians and physician assistants are facing to make recommendations for a change in policy or practice. The ombuds team does not have the authority to mandate that any visitor do anything they choose not to do.

11. What happens to information provided to the ombuds team? What gets reported to Sutter Health?

Because it is a confidential resource, the ombuds team does not keep identifying information from individual cases. Any recordkeeping or note-taking related to a specific case will only be used to help informally manage or resolve physicians and physician assistants’ concerns and will be anonymized after the case is closed and/or follow-up is complete.

The ombuds team keeps aggregate statistics and periodically provides updates to medical group presidents and Sutter Health. The ombuds team will review data with an eye towards highlighting emerging issues, identifying trends, highlighting vulnerable groups, and suggesting areas of improvement.

12. Should you contact the ombuds team to give notice of a formal complaint to Sutter Health?

No. Discussions with the ombuds team are off-the-record and do not constitute formal notice to Sutter Health. The ombuds team cannot accept notice for Sutter Health or initiate a formal process like an investigation or grievance. If you have a complaint and want to pursue a formal remedy, the ombuds team can refer you to the appropriate person at Sutter Health. You can still contact the ombuds team to discuss the problem that you would like addressed, with the goal of resolving the matter. Any formal complaints should be reported to the proper organizational resource.

13. How does the ombuds team remain impartial?

The ombuds team’s effectiveness and credibility is based on a commitment to being fair and supportive of each physician and physician assistant who contacts the ombuds team. The ombuds team is not part of any one department at Sutter Health and are independent subcontractors to Sutter Health, which allows the ombuds team to be impartial. The ombuds team’s job is to help physicians and physician assistants make informed decisions for themselves with the ombuds team’s assistance and support.

14. Will the ombuds team participate in formal meetings?

No. The ombuds team cannot serve as a witness and does not participate in any formal grievance process. The ombuds team will not testify in formal judicial or administrative hearings. However, the ombuds team is available to facilitate informal discussions with the consent of the other participants. If the ombuds team is asked to serve on a committee, it will be done in an advisory or ex-officio capacity only.

15. How is the ombuds team unique and different than other resources at Sutter Health?

The goal of the ombuds team is to proactively seek to educate and inform Sutter Health physicians and physician assistants about conflict management options to address and resolve concerns. In addition, the ombuds team offers a confidential, independent, and informal resource for Sutter Health’s physicians and physician assistants, unlike other departments at Sutter Health. This means that physicians and physician assistants can speak with the ombuds team with the assurance that the ombuds team will not report what was told unless someone would be harmed if nothing was reported. Also, the ombuds team is a change agent who identifies patterns and causes of conflict at Sutter Health and brings those issues to the attention of Sutter Health for implementation.

16. Are there any instances in which the ombuds team will not be able to maintain confidentiality?

Yes. If the ombuds team determines that an imminent threat of serious harm exists and/or there is suspicion of abuse of any kind, the ombuds team is obligated to disclose this information. This determination will be made at the sole discretion of the ombuds team. Situations in which the ombuds team believes that talking with other individuals may help, and there is not a risk of harm to self or others, the visitor will be asked for permission before any disclosures are made. If a visitor has particular concerns about confidentiality, they can raise the issue with the ombuds team. This confidentiality cannot be “waived” by users of the ombuds service because the privilege of confidentiality belongs to the ombuds team and not to the users of the service. Because confidentiality is so important to the ombuds team, all communications with the ombuds team are made with the understanding that they are confidential, off-the-record, and that the ombuds team will not be called to testify as a witness in any formal or legal proceeding to reveal confidential and/or privileged communications.

17. Will the ombuds team talk to your attorney or testify for you or for Sutter Health if you choose to file a grievance or lawsuit?

No. Once a matter is in a formal process, including legal action, the ombuds team does not have any further involvement, unless the parties want to try mediation or other confidential services of the ombuds team in an attempt to resolve the issue. The ombuds team will maintain the confidentiality of all dealings and communications and will assert any and all legal protections to maintain that confidentiality. The ombuds team reserves the right to uphold confidentiality even when the person using the services of the ombuds team requests disclosure.

18. If you reach out to the ombuds team can you remain anonymous?

Yes, visitors can remain anonymous. They can call the ombuds team to discuss the issue without giving a name.

19. Will a member of the ombuds team tell you what to do?

No. They will not and cannot provide legal advice or make decisions on behalf of the visitor or Sutter Health, but they will rather help visitors figure out what resources are available to and appropriate for them. Additionally, they will not do anything without a visitor’s permission.

20. Can you choose which member of the ombuds team to interact with?

Yes. It was important for us to ensure the ombuds team could serve the diverse needs of our physicians and physician assistants based on professional and personal background and experience. At this time, we have three ombuds team members dedicated to serving Sutter Health’s physicians and physician assistants whose bios can be found here. You have the option to select a team member to partner with based on your individual preferences.

21. Will going to the ombuds team automatically trigger an investigation?

No. Since the ombuds team is independent of Sutter Health and informal, going to the ombuds team will not register a formal complaint with Sutter Health. The ombuds team’s approach is to help visitors develop an action plan and steps to get there.

22. Who are the members of the Sutter Health Ombuds Team? How are they trained/vetted?

Each member of the ombuds team has been trained by International Ombuds Association (IOA) and practice in accordance with the IOA’s Standards of Practice and Code of Ethics. They were selected for their cultural competency and awareness and have years of experience supporting people through similar programs at other organizations.

23. How do you know that your visit will cause something to change?

The ombuds team operates on two levels – as a sounding board for physicians and physician assistants, and also as a data-gathering / anonymizing / aggregating platform to identify systemic issues. At the individual level, the ombuds team creates options (including the possibility of not taking action) for the visitor to be able to address the situation, not to tell them prescriptively what to do. The ombuds team is not a reporting mechanism, so if direct change is desired, physicians and physician assistants should use the appropriate channel(s).

At the institutional level, Sutter Health will receive a periodic report that highlights trends or themes or particular hotspots along with actionable recommendations on how to address the concerns effectively. However, the ombuds team cannot mandate that Sutter Health take action.

24. You want to reach out to the ombuds team, but you are nervous. Is there any way for the Sutter Health to identify you as a visitor?

No. The effectiveness of the ombuds team is dependent on members of the ombuds team not revealing who reached out to them. Maintaining the confidentiality and anonymity of those who go to the ombuds team is a defining principle of the resource. The ombuds team has access to some contact information and general employment data of Sutter Health’s physicians and physician assistants, which is used to verify eligibility to use the ombuds team service and help identify patterns and trends that inform recommendations to senior leadership. All personal identifying information is redacted once the case is closed, the remaining data is aggregated, and no information that could identify visitors is used in reports. Physicians and physician assistants are welcome to reach out to a member of the ombuds team with additional questions about confidentiality

25. What if your question is not listed here?

Please contact any of the Sutter Health Ombuds, at https://www.mwi.org/sh-ombuds/ to get your questions answered.