Part 3 in a 3-part series

How to manage patient grievances

Key steps for your grievance process

By Patrice Spath, ART

Brown-Spath Associates

Forest Grove, OR

Ultimate responsibility for resolving patient grievances lies with the hospital’s governing board. However, the board members must rely on the recommendations of the people involved in investigating the grievance. In many instances, it is best for the governing board to delegate the operational aspects of the grievance process to a multidisciplinary committee. However, the governing board should make sure the hospital has a clearly defined and impartial process for resolving patient grievances. Not only is such a process required by the Medicare Conditions of Participation (COPs), but it is also an important aspect of quality customer service.

The grievance procedure should encourage open communication between patients and hospital staff on issues, problems, or complaints. Patients must be offered assistance in formulating and submitting grievances and timely resolution of problems. Most complaints may be more effectively addressed and resolved by informal means than by invoking the formal grievance procedure. Still, it must be made clear to patients that they have the right to have their concerns heard by upper levels of management.

The key steps of a grievance process are described below. A two-step review procedure is presented. However, hospitals may choose to shorten the process, as the COPs do not mandate that a particular procedure be followed.

When a formal grievance is received from a patient, a disposition decision must be made. Is the concern one that the hospital must investigate? If the complaint would be more appropriately directed to another facility, group, or individual, then a hospital representative should help facilitate contact between the grievant and the appropriate party. Patients may feel uncomfortable approaching a health plan or another provider with a complaint, and the hospital should assist them in making their concerns known. Some hospitals provide patient advocate or ombudsman services to assist patients and their families with any concerns related to the health care experience.

If the grievance should be reviewed and resolved by the hospital, then the next disposition decision is to determine who should be involved in the initial review of the complaint. Grievance resolution must be timely, and holding a grievance committee meeting for every formal complaint may delay the process. It is especially important that formal complaints about quality of care or premature discharge be resolved very quickly.

In order to act quickly, it is advantageous to have a first-level review process in which a small group of individuals evaluates the situation and makes a determination regarding how the situation can be resolved. This group may include the patient advocate or the person charged with overseeing the grievance process, the chief executive officer or his or her designee, and the director of the department involved in the complaint. If the grievance is about the quality of care provided by physicians or a discharge decision with which the patient disagrees, then the medical director or the physician chief of service should be included in the first-level review discussions.

If the grievance represents an immediate and serious threat to patient health and safety, the organization must have an expedited first-level griev ance review process. Otherwise, the group should meet within the time frame defined by the hospital’s policies (generally no later than 10 days after the grievance is received). People must be given adequate time to review relevant details about the situation before meeting. At the first-level review meeting, the group should have sufficient information to be able to decide how to handle the griev ance. The group should be authorized to resolve a grievance in any manner it regards appropriate, as long as it does not exceed the lawful authority of the organization. If the group is unable to reach a decision, it may recommend the issue be forwarded to a grievance committee that is composed of broader representation.

It is hoped that most grievances can be resolved in the first-level review process. On rare occasions, a grievance committee may need to be appointed to resolve first-level review deadlocks or when the grievant requests a reconsideration of the initial decision. It is up to the hospital leaders to decide which departments and disciplines should be appointed to serve on this committee. If the hospital has a formal ethics committee, this group could be charged with investigating and rendering second-level decisions on complaints. If the hospital lacks an ethics committee, the grievance committee could be established as a task force of the governing board.

Ensure grievance committee’s impartiality>

The members of the grievance committee should not be members of the group who initially reviewed the grievance. It is also important to be sure the members of the grievance committee have no actual or apparent bias or conflict of interest. Examples of conflicts of interest include people who will potentially benefit or lose from a decision and anyone who has previously been involved in any attempted resolution of the complaint.

A problem with many complaint investigation procedures is the perceived lack of impartiality. Dissatisfied patients do not expect or want the people they are complaining about to be the ones deciding the validity of their complaint. The hospital may want to allow patients or their representatives to appear in person before the grievance committee to state their case. Likewise, it may be helpful to include as a grievance committee member someone from the clergy and/or a community representative who is not affiliated with the hospital in any way. The committee can ask other people to provide information pertinent to the complaint. Such information may be provided in person or in writing. All parties should be given a full and fair opportunity to respond to all information gathered by the committee.

When grievance committee members are satisfied that they have adequate information, they should reach a consensus decision. If the committee is unable to reach a decision, it may recommend the formation of a new grievance committee to re-hear the dispute, or the issue may be forwarded to the governing board for final resolution.

When a final decision is reached, a written response is provided to the patient who initiated the grievance. This response should include a restatement of the issue under inquiry, the date the review process was completed, the steps that were taken to investigate the complaint, the final decision of the review group, and any corrective actions the facility may be implementing. If the issue involves quality of care or premature discharge, be sure to remind the patient of other avenues for voicing concerns (e.g., state regulatory agencies, professional review organization, Health Care Financing Administration, etc.). Remember to provide a phone number and address for each group that may be mentioned in the letter.

The response letter should also explain the process for reconsideration if the patient is unhappy with the results of the investigation. If the patient is still not satisfied with the proposed resolution of a grievance, the organization may choose to provide additional opportunities for further consideration, or the decision may be final at this point. Be sure the information you provide to patients about your grievance process clearly defines the number of reconsiderations that are allowed. Generally, only one reconsideration is allowed unless the patient can show evidence of bias and/or procedural irregularities or if new information not previously available comes to light.

There should be a process for tracking each grievance until its final resolution. Someone must be responsible for monitoring the grievance review process to be certain that each required step is completed within the time frame specified in the organization’s grievance procedures. Also, the hospital’s governing board should receive reports of the status of all grievances received, actions taken to resolve disputes, committee recommendations, and the status of corrective action plans.

Over the past year, the public has grown increasingly concerned about protection of patients’ rights. Hospitals must respond by implementing a fair and impartial grievance process. Whatever procedure is used to respond to grievances, what’s most important is that patients feel they can address problems they identify in the treatment they receive without fear of discrimination or reprisal.