1. Establishing a Hospital Patient
Grievance Process
Lisa Venn, J.D. M.A.

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

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

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

5. History
2009, Joint Commission standards mirror CMS Patient Grievance CoP/Interpretive Guidelines

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. A Grievance IS: Patient initiated EMTALA and HIPAA complaints Step 2

14. 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

15. 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

16. 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

17. 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

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

19. 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 CFR (a)(2)(iii)

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

21. 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

22. 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

23. 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