Guidelines show when an issue becomes grievance’

The Society for Healthcare Consumer Advocacy, part of the American Health Association, has developed a document outlining when a patient issue should be categorized as a grievance under Center for Medicare & Medicaid Services’ (CMS) regulations. It developed the document based on discussions with top CMS staffers, prompted by requests for clarification from risk managers and other health care professionals.

The document identifies differences between a patient complaint and grievance and provides tips for discussing complaint and grievance issues with state surveyors. It can be found at www.shca-aha.org. This is some of the advice:

  • An issue is not a grievance if it can be handled on the spot by staff present.
  • An issue is not a grievance if the patient (currently in the hospital) calls the patient representative first and has not yet tried to resolve the issue with the involved department. The patient representative can forward the issue to the involved department(s) for resolution and consider it a complaint. However, if the issue comes back to the patient representative as unresolved to the patient’s satisfaction, it escalates to grievance status.
  • If other staff must be called in (i.e., the patient representative) after staff present have failed to resolve the issue, then the issue is considered a grievance in most cases.
  • Billing issues are not considered grievances unless the patient is disputing charges due to poor care or service.
  • All issues from patients who call or write to the hospital after discharge are considered grievances because the issues were not resolved during their stay.