Be sure you're complying with patient rights regs

Is your patient access staff familiar with federal requirements for giving patients information on how to file complaints or grievances?

The Joint Commission's complaint resolution standard, effective July 2009, now more closely resembles the Centers for Medicare & Medicaid's Patient Grievance Condition of Participation. Both organizations require the patient and his or her family to be informed about the complaint and grievance resolution process, and to be provided with the phone number and address needed to file a complaint or grievance with the relevant state authority.

Vicki Lyons, patient access manager at Baptist Hospital East in Louisville, KY, says that patients are given a packet during registration including a Notice of Privacy Practices, an informational sheet on patient safety, information on requests for private rooms, a letter to the patient from patient relations explaining how to file a grievance and who to call, a patient rights paper, a pain control guide, information on smoking cessation programs, what to do if they need help during the hospital stay, and a phone card so staff can tell them the phone number in their room to give to their families.

"We do not verbally tell the patients how to file a grievance. When they are handed the information, we tell them it is information they need to know while in the hospital," says Lyons.

When patients sign the conditions of admissions form, it is marked that they have received a copy of the patients rights and responsibilities. In addition, patients are given a statement acknowledging being offered a brochure on their rights to make decisions about their medical care and advance directives.

"We have a statement stating that they did receive a copy of the notice of privacy, or that they did not receive a copy because they had received one previously," says Lyons. "A lot of our patients are repeat patients and choose not to take the information again, but we do always offer it."

[For more information, contact:

Vicki Lyons, Patient Access Manager, Baptist Hospital East, 4000 Kresge Way, Louisville, KY 40207. Phone: (502) 897-8159. E-mail:]