SDS Accreditation Update

Patient grievance process is given a second look

In 1999, the Centers for Medicare & Medicaid Services (CMS) established a hospital Patient's Rights' Condition of Participation (CoP). CoPs are the minimum health and safety standards that health care providers must meet to participate in the Medicare and Medicaid programs. The Patient's Rights' CoP guarantees a patient the right to receive information and requires hospitals to establish a patient grievance process.

Though in effect since 1999, the patient grievance mandate contained in the Patient's Rights' CoP essentially lay dormant until CMS published its Interpretive Guidelines. The guidelines, effective Sept. 19, 2005, defined "grievance" and set forth time frames by which a hospital must investigate and resolve patient grievances. The guidelines also require hospitals to:

  • inform the patient and/or the patient's representative of the hospital's grievance process, including the right to file a grievance with the state agency;
  • coordinate its existing mechanism for utilization review notice and referral to the Quality Improvement Organization (QIO) for Medicare beneficiary concerns;
  • keep data on all complaints and grievances;
  • incorporate grievance data into the hospital's quality improvement process.

A similar process is in place for ambulatory surgery centers in light of the May 18, 2009, Medicare Interpretive Guidelines.

So why should a facility take a new look at its patient grievance process? According to Lisa Venn, JD, MA, manager of compliance at University Hospitals in Cleveland, the reason lies in The Joint Commission's loss of statutory deeming authority. Venn says when Congress revoked The Joint Commission's unique deeming authority in July 2008, The Joint Commission had to apply for deeming authority just like every other accreditation organization. As part of its deeming authority application, The Joint Commission revised its standards and elements of performance (EPs) in an effort to demonstrate that they are equal to or stricter than CMS' Conditions of Participation. As part of the standards revision process, she says, The Joint Commission significantly overhauled its complaint resolution Standard RI.01.07.01. Now, The Joint Commission's complaint resolution standard more closely resembles CMS' patient grievance CoP. Venn notes that, while effective, these standards are under review by CMS.

Before the revision, The Joint Commission standards were relatively silent on the issue of the patient complaint process and hence not the focus of Joint Commission surveyors, explains Venn. A facility "should take this opportunity to prepare for a surveyor's review of its patient grievance process," says Venn.

Complaint or grievance — have a policy

Another committee? This doesn't have to be a frustrating item on your to-do list. If you don't have already have a committee to deal with grievances or complaints, build from what you already have in place to do it, suggests Sue Dill Calloway, RN, Esq., BSN, MSN, JD, director of hospital patient safety at The Doctors Co. in Columbus, OH.

CMS and The Joint Commission require committees, and both give sole responsibility of owning the process to the facility's governing body, which can delegate responsibilities to a special committee. CMS refers to a grievance committee and The Joint Commission calls this a complaint resolution committee. Whatever it's called, Calloway has some suggestions on who needs to be at that table.

Calloway recommends it be multidisciplinary. Generally, the person responsible for risk management should be included, she says. Patient safety "probably" should be, as well as your privacy/security officer. Calloway says the consumer ombudsman usually runs it, and if you have internal legal counsel, she suggests including them as well.

She also suggests including the patient satisfaction personnel or the staff who are responsible for reviewing patient satisfaction surveys since those might contain complaints or grievances that must go through the process.

If you're thinking, "'Oh man, another committee,'" she suggests looking at "what committee do we have right now that meets that everybody who we need is probably going to be there so that when we're done, we can just reconvene and have the people stay over?" In one hospital she worked for, the performance improvement committees was large, and almost everybody was required to sit in. So when that meeting ended, grievance committee members were simply asked to stay for a short meeting.

Because there is not much guidance on how the committee should build its agenda, she says her committee, in looking at revising its policy, would look especially for system-related issues. "We drafted a policy that really specified what the committee was going to do and how important it was. And you need to put that in your patient safety plan. You should have a patient safety plan and a PI plan because you need to know how that correlates with your plan," she says.