www.advocatealliance.net establishing a hospital patient grievance process lisa venn, j.d. m.a
TRANSCRIPT
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Establishing a Hospital Patient Grievance Process
Lisa Venn, J.D. M.A.
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Objective
To provide a step-by-step guide to creating or fine-tuning a hospital patient complaint and grievance process.
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History
On July 2, 1999 HCFA (now CMS) established a patient’s’ rights’ Hospital Condition of Participation (CoP).
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History
Effective September 19, 2005, CMS issued Interpretive Guidelines
Clarifying the patient grievance process
Revising the definition of grievance Detailing the grievance response
requirements
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History
2009, Joint Commission standards mirror CMS Patient Grievance CoP/Interpretive Guidelines
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Steps to Establishing a Patient Grievance Process:
1. Establish a grievance committee2. Write policies and procedures3. Educate patients4. Educate staff5. Investigate6. Resolve7. Document8. Incorporate grievance data into the hospital
quality process
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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
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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
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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
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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
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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
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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
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A Grievance IS:
Patient initiated EMTALA and HIPAA complaints
Step 2
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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
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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
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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
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Investigate
1. Interview complainant and patient2. Gather facts3. Identify steps already taken to handle concern4. Research regulations, laws, hospital P & P5. Review patient records6. Make observations
Step 5
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Resolve
A grievance is resolved when the patient is satisfied with the actions taken on their behalf.
Step 6
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Resolve
Resolution includes follow up. Follow up letter must include:
1. Name of the hospital contact person2. Investigative steps3. Results of the grievance process4. Date of completion
Step 6 42 CFR 482.13(a)(2)(iii)
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Document
1. Grievance description – complainant/patient2. Patient consent to investigate3. Steps taken to resolve the grievance4. Investigation outcome5. Follow up letter
Step 7
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Incorporate Grievance Data intoThe 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
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Incorporate Grievance Data intoThe 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
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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