Practice Tips

Patient and family complaints can create an opportunity to review a service, process, or procedure from a perspective that we in healthcare do not always see. According to the Risk Management Handbook for Health Care Organizations, "Every complaint, regardless of the lack of direct ramifications, contains valid feedback and should be addressed by the organization." The true value in patient complaints and grievances can be in what organizations do with the lessons learned and possibly improve the patient's perception of the organization.

Regular Monitoring of Complaints

Tracking and trending patient complaints and grievances can help healthcare organizations identify issues within the hospital requiring attention and implement the appropriate action. The patient complaints and grievances process should be centralized into one tracking system, either electronic or paper, to enable tracking and trending. By centrally locating the process, grievances can be addressed and acted upon consistently and uniformly. Having a centralized system will ensure each patient or family receives a response to their complaint or grievance in a timely manner, reviewing data for trends and implementing improvement initiatives to address trends identified.

Is it a Complaint or a Grievance?

The Center for Medicare and Medicaid Services (CMS) distinguishes between complaints and grievances. According to CMS, a complaint is a minor patient issue that can be resolved promptly, within 24 hours or before the patient is discharged, such as a meal preference or environmental concerns. Complaints are usually addressed by staff who are present at the time of the complaint and can resolve the concern at that time, such as a nurse, housekeeper, or physician. Complaints that involved staff members that were resolved at the time of the complaint generally do not require a written response. However, even if a patient's complaint is addressed quickly and informally, the facility should document the complaint and its actions to resolve it. Maintain records for quality improvement activities.

When complaints are more complex and cannot be resolved during the patient's stay in the facility prior to discharge, the patient can file a formal grievance. A grievance "is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS CoPs, or Medicare beneficiary billing related to rights and limitations provided by 42 CFR 489." (CMS) Grievances can be verbal, by telephone, written, emailed, faxed, or through patient satisfaction surveys if there is a written complaint on the survey and a request for a response. When a hospital receives a written complaint from a patient after discharge from the facility, CMS considers this a grievance. If there is a question of whether a complaint is a grievance, it is best to err on the side of caution and treat the complaint as a grievance.

Healthcare facilities are not required to use the same terminology as CMS to describe complaints and grievances; however, they must follow the guidelines outlined in the Conditions of Participation, 42 CFR 482.13 (2006).

Informing Patients and Families of Their Rights

Patients and family members have legal rights when they are admitted to a healthcare facility. The organization should have processes to inform patients and family members of their rights soon after admission to the facility. The information provided should be explained in a language the patient or patient's representative can understand.  Most organizations have a Patient's Bill of Rights document included in their admission packet. One of the patient's rights is the right to file a complaint or grievance about the care they received and that their decision to file a complaint or grievance will not compromise their care. Patients need to be informed how they can file complaints during their hospital stay and after discharge from the facility. Patients must be provided with the appropriate information to file a grievance internally, including whom to contact in the hospital, and with the appropriate regulatory agencies, including the address and phone number of those agencies. The facility should require the patient or patient's representative to sign a form to acknowledge they were informed of their rights and received information on the grievance process.

Responding to Patient and Family Complaints and Grievances

Healthcare organizations should have processes in place to respond to patient and family complaints and grievances. CMS and the Joint Commission require an organization's governing body to approve and oversee its complaint and grievance process. The governing body can delegate this responsibility to a grievance committee.

The organization should develop written policies and procedures to guide staff in responding to patient and family complaints and grievances. Staff should also receive education and training on how to respond appropriately to patient and family concerns. These policies must establish timeframes for responding to formal grievances. Grievances pertaining to issues that pose an immediate danger to a patient, such as abuse or neglect, must be addressed immediately. For other grievances, CMS considers a written response within seven days to be appropriate. If the issue is complex and will take longer than seven days to resolve, a letter should be sent to the patient informing them that the issue is being reviewed, and they will receive a written response within a specific timeframe.

The way staff react to and address a concern can make the difference between the concern being resolved quickly or becoming a more significant issue that requires many hours of staff time and possibly litigation. Education on listening, communication, and conflict management skills can help staff members respond appropriately to patient and family concerns.

Listening to the patient or family member and responding with empathy and compassion can often resolve the issue. If the problem is more complex and requires more detailed intervention, the staff member dealing with the patient should notify their supervisor, the patient relations coordinator, or the risk manager.

Written grievances or complex grievances require in-depth investigation. This investigation will include talking to the patient and or family members, reviewing the medical record, talking to the staff members involved and staff members who were not involved but who might have witnessed the occurrence. When grievances are serious, possibly leading to a malpractice claim, the risk manager should be consulted. The risk manager possesses the knowledge and expertise to guide these investigative processes.

Once the grievance is resolved, the organization must provide the patient with a written response that includes a description of the steps taken to investigate the issue, the results of those actions, the date of the completion of the grievance process, and the name of a contact person at the hospital. The response should be in clear and easily understandable language. There will be instances when actions taken by the facility are confidential, and details should not be included in the letter. In these cases, it is appropriate to state, "appropriate action was taken." The facility must respond promptly (usually within 7 days). Grievances concerning situations that may endanger the patient (e.g., neglect, abuse) should be given the highest priority and should be addressed immediately. If an investigation cannot be completed or the grievance cannot be resolved within 7 days, the patient or patient's representative should be informed that the process is ongoing and will receive a written response within a specified time period. If the grievance was received via email, it is acceptable for the organization to respond via email.

According to CMS regulations, a grievance is considered resolved when the patient is satisfied with the actions taken on their behalf or when the facility has taken "appropriate and reasonable" measures to resolve the grievance, even if the patient or patient's representative is unsatisfied with the response. When the patient (or representative) remains dissatisfied, the facility must provide contact information for entities outside of the facility, such as CMS, Medical Board, Office of Professional Regulation, or Ombudsman. Facilities should consider meeting with patients or patient representatives to resolve the grievance if possible and maintain documentation of all its efforts.

Sometimes, an organization might consider waiving a portion of a bill as a result of their investigation. There are legal and regulatory issues, including fraud and abuse laws and insurance coverage issues, that can be involved in waiving a patient's bill. If the hospital considers waiving a bill, they should consult with their compliance department, legal counsel, and malpractice insurance carrier.

Hospital-based physician office practices or other off-site departments (PT, Radiology, etc.), defined as hospital departments, must also have a complaint and grievance process. This process should be integrated within the hospital's complaint and grievance process. Patients must be informed of this process within the practice setting, and information should be provided to the patient or patient representative.

Peer Review

Most state laws protect the results of peer review from discovery. Peer review information should not be shared or discussed outside of the peer review committee or structure. Sometimes, hospitals and physicians want to share the results of their review to substantiate that the care received was adequate. Unfortunately, they have breached their protection when this is done, making all peer review documents vulnerable to discovery.

Centers for Medicare and Medicaid Services (CMS)

The hospital is not required to include statements that could be used in legal action against the hospital, but it must provide adequate information to address the requirements. Please see CMS Hospital Conditions of Participation for further details.

If a Claim Arises

In some instances, a claim cannot be avoided. If a claim is made, contact your malpractice insurance carrier as soon as possible. A claims representative will assist you with this process, whether it be the defense or settlement in the case.

Resources

ECRI, Managing Patient Grievances and Complaints, Published August 17, 2016

CMS, 42 CFR 482.13 (2008) revision 37, issued 10-17-08; Effective/Implementation Date: 10-17-08