Establishing a Hospital Patient Grievance Process Lisa Venn, J.D. M.A. www.advocatealliance.net

Objective To provide a step-by-step guide to creating or fine-tuning a hospital patient complaint and grievance process. www.advocatealliance.net

History On July 2, 1999 HCFA (now CMS) established a patient’s’ rights’ Hospital Condition of Participation (CoP). www.advocatealliance.net

History Effective September 19, 2005, CMS issued Interpretive Guidelines Clarifying the patient grievance process Revising the definition of grievance Detailing the grievance response requirements www.advocatealliance.net

History 2009, Joint Commission standards mirror CMS Patient Grievance CoP/Interpretive Guidelines www.advocatealliance.net

Steps to Establishing a Patient Grievance Process: Establish a grievance committee Write policies and procedures Educate patients Educate staff Investigate Resolve Document Incorporate grievance data into the hospital quality process www.advocatealliance.net

Establish a Grievance Committee Governing body has full responsibility for ensuring compliance with CMS grievance regulations Governing body may delegate the process to a committee Delegation must be in writing Step 1 www.advocatealliance.net

Write Policies and Procedures CMS requires hospitals to have written policies and procedures by which to identify and address a patient grievance in a timely manner. Step 2 www.advocatealliance.net

Write Policies and Procedures Hospital grievance procedures must include: Means to identify a grievance Incorporation of QIO referral process Grievance investigation and resolution steps (including time frames and follow up letter) Documentation protocols Step 2 www.advocatealliance.net

Correct Identification of a “Grievance” is Key to a Successful Grievance Program Accurate identification of a Grievance is essential to complying with the CMS Patient Grievance CoP A grievance triggers the need for a formalized investigation and response. Step 2 www.advocatealliance.net

A Grievance is NOT Issue resolved on the spot by staff present Non-Medicare billing issue Patient survey response without an attached complaint and request for resolution Step 2 www.advocatealliance.net

A Grievance IS: Any concern which a patient requests be handled as a formal complaint. Medicare billing/coverage issues Patient survey response: - with attached complaint and request for resolution - with attached concern which would have been considered a grievance Step 2 www.advocatealliance.net

A Grievance IS: Patient initiated EMTALA and HIPAA complaints Step 2 www.advocatealliance.net

A Grievance IS: Concern involving patient care Concern alleging abuse or neglect Concern pertaining to hospital’s compliance with CMS CoPs Medicare beneficiary discharge dispute Step 2 www.advocatealliance.net

Educate Patients Must notify of right to lodge a grievance with the State agency directly, regardless of whether he or she first used the hospital’s grievance process Must give State agency phone number and address Step 3 www.advocatealliance.net

Educate Employees The hospital must educate employees at every level about the process. All employees must be instructed to identify a grievance so that the grievance process can be followed. Step 4 www.advocatealliance.net

Investigate Interview complainant and patient Gather facts Identify steps already taken to handle concern Research regulations, laws, hospital P & P Review patient records Make observations Step 5 www.advocatealliance.net

Resolve A grievance is resolved when the patient is satisfied with the actions taken on their behalf. Step 6 www.advocatealliance.net

Resolve Resolution includes follow up. Follow up letter must include: Name of the hospital contact person Investigative steps Results of the grievance process Date of completion Step 6 42 CFR 482.13(a)(2)(iii) www.advocatealliance.net

Document Grievance description – complainant/patient Patient consent to investigate Steps taken to resolve the grievance Investigation outcome Follow up letter Step 7 www.advocatealliance.net

Incorporate Grievance Data into The Hospital Quality Program “Regardless of the nature of the grievance, the hospital should make sure that it is responding to the substance of each grievance while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance.” Step 8 www.advocatealliance.net

Incorporate Grievance Data into The Hospital Quality Program Surveyors may ask: Does the hospital apply what it learns from the grievance as part of its continuous quality improvement activities? Is the grievance process reviewed and analyzed through the hospital’s Quality Assurance Process Improvement (QAPI) process? Step 8 www.advocatealliance.net

Summary Establish the grievance committee Write policies and procedures Educate patients and staff Investigate, resolve and follow up Incorporate into quality process Document, document, document www.advocatealliance.net