Complaints – Patients in Acute Healthcare Facilities
Patient and family complaints originate from their experiences, perceptions, and impressions. These complaints though challenging at times 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.” With healthcare organizations and providers recognizing the value of patient-centered care, and calls for transparency of patient satisfaction data, addressing patient and family complaints and grievances has taken on greater emphasis in the need to improve patient care and service. 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
The establishment of patient representative programs can assist in providing information on current or developing problems and offer a channel for prompt resolution of minor problems before they become major problems. If the position of a patient representative is not possible for the facility, another system should be established to monitor complaints and potential issues. Often, managers and their staff can be trained to recognize the complaint type and theme, and address them when they arise. 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 in a consistent and uniform manner. Having a centralized system will assure each patient or family receives a response to their complaint or grievance in a timely manner, review of the data for trends and implementation of improvement initiatives to address any 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 are able to resolve the concern at that time, such as a nurse, housekeeper, or physician. Complaints that can be resolved by the involved staff members at the time of the complaint generally do not require written response. However, even if a patient’s complaint is addressed quickly and informally, the facility should document the complaint and the actions taken to resolve it. Maintain the records for quality improvement activities.
When complaints are more complex and/or cannot be resolved during the patient stay in the facility, prior to discharge, then 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 from patient satisfaction surveys if there is a written complaint on the survey and there is 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 staff is in doubt as to whether a complaint is a grievance it is best practice 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 are required to 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 in place to inform patients and/or family members of their patient rights soon after they are admitted into the facility. The information provided should be explained in a language or manner the patient or patient’s representative can understand. Most organizations have a Patient's Bill of Rights document, which may be part of 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 the care they receive. Patients need to be informed about how they can file the complaint during their patient stay in the hospital and after they are discharged from the facility. Patients must be provided the appropriate information to file a grievance internally, including whom to contact, and with regulatory agencies, including the address and phone number of those agencies. The facility should require the patient sign a form to acknowledge they were informed of their rights and they 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 provide oversight with the complaint and grievance process in the organization. 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. In addition, staff should 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 that pertain to issues related to posing 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 certain timeframe.
The way staff react to and address a concern can make the difference between the concern being resolved quickly or it becoming a larger 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.
Responding with empathy and compassion can help defuse many difficult situations. Skills such as giving the patient undivided attention, repeating back what you heard the patient say, and acknowledging the patient's frustration make the patient feel that you care and are willing to hear their side of the situation.
Many times just listening to the patient or family member can resolve the issue. If, however, the issue 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. Patient relations coordinators or a designated individual, often coordinate the investigation and response to grievances. When grievances are of a serious nature, 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.
After the investigation is completed, the organization will take the appropriate action to resolve any issues that were identified. This may include updating policies and procedures, corrective action plans for employees or the case being forwarded to the peer review process or committee of the medical staff. In some cases the investigation may determine that the patient misinterpreted certain aspects of the situation. Responding to the grievance will give the organization an opportunity to clarify the situation and possibly improve the patient's perception of the organization.
After the grievance has been resolved, the organization must provide the patient with a written response that includes a description of the steps that were 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 provide the response in a timely manner (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 that they 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” actions to resolve the grievance even if the patient or patient’s representative is unsatisfied with the response. 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 as well as insurance coverage issues that can be involved in waiving a patient's bill. If the hospital is considering waiving a bill they should consult with legal counsel and their malpractice insurance carrier.
Hospital-based physician office practices or other off-site departments (PT, Radiology, etc.), which are defined as departments of the hospital 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.
Most state laws protect 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, when this is done, they have breached their protection, 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 a legal action against the hospital but it must provide adequate information to address the requirements. Please see CMS Hospital Conditions of Participation for further information.
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.
ECRI, Managing Patient Grievances and Complaints, Volume 2, September 2010
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
Medical Mutual Insurance Company of Maine's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.