Effective patient grievance policy can be vital tool for improvement

Every facility is different; make sure policy fits your organization

They may not grab many headlines, but grievance policies and procedures are, nonetheless, a critical component of a thorough, effective quality improvement effort.

Furthermore, quality professionals say, all grievance policies are not created equal — it really does make a difference who sits on your committee or task force, how your policy is constructed, and whether it is adequately customized to your facility or system.

"There are a number of good reasons [for having patient grievance policies and procedures]," says Matthew Rosenblum, chief operations officer for privacy, quality management, and regulatory affairs with CPI Directions Inc., a New York City-based consulting firm that specializes in performance improvement and regulatory compliance functions.

One important consideration, he says, is the context within which care is provided. "By that, I mean when people come to the hospital they are usually hurt and scared in some way, and as a consequence, their complaints may be easily aroused."

For the provider, Rosenblum adds, it’s important to be able to recognize when a complaint also is a grievance. "In medical terms, we generally refer to how patients say they were hurt as a complaint. True grievances can include neglect, abuse, payments, insurance, reimbursement matters, or privacy. When a complaint comes in writing or through a third-party organization, then it’s official, and it should be responded to with very appropriate actions."

An effective grievance policy can ensure consistent staff responses, Rosenblum continues.

"If you have designated steps to resolve complaints and mitigate any harmful effects that have occurred, hopefully, situations can be resolved before they become official," he adds. "So, for example, staff should engage patients in a calm manner and express concern about what the patient is saying. This way, the patient feels better about our potential response." A consistent staff response also helps ensure timely and complete responses, and a good policy keeps staff aware that they need to be faithful to their ethical and legal obligations — i.e., to treat every patient equally, with no retaliation for complaints.

Finally, such a policy can make an important contribution to your continuous performance improvement efforts, Rosenblum notes. "The level of satisfaction with the care we provide is a rich source of information for improving. We need processes and technologies in place to accurately capture what our patients tell us and to analyze it proactively."

For example, you might want to conduct a failure mode and effect analysis (FMEA) on what patients complain about, or you could study complaints retrospectively through root-cause analyses. "You may also use it to improve patient relations," he adds.

The bottom line: Many quality professionals would have such policies and procedures in place even if there were not a regulatory requirement to do so. "The no-brainer answer is you have to have one because it is a CMS [Centers for Medicare & Medicaid Services] requirement," says Cathy S.C. Stouffer, customer service/patient safety officer at Freeport (IL) Health Network. "But besides that, you need to be prepared for the times when patients are concerned that an organization may have made a decision they are not satisfied with," she points out.

"This has grown out of the patient rights movement; it started many years ago, and it has kept evolving," notes Sue Wedemeyer, RN, BSN, MBA, clinical manager for loss prevention for Catholic Health Initiatives in Erlanger, KY.

"We always depended on some sort of patient satisfaction survey, but we’ve gone beyond that. Now, there’s a lot more emphasis on patients’ rights, and because of regulatory requirements, it became much more formal," she says.

If you are creating a new set of policies and procedures or re-examining your existing ones, who should comprise your committee or task force? "No. 1, you have to have the customer relations person," Stouffer says. "Then include the quality department — they are the ones who will spearhead process improvement, and that’s the goal, to improve processes. Medical directors also should be included." CMS suggests that it be structured very much like your ethics committee and include someone from the outside, she notes. "It might even be helpful to include the chair of the ethics committee," Stouffer suggests.

"It really depends on the institution," explains Wedemeyer. "Certainly, you must include whoever is designated as the point person. Then the risk manager, the quality manager, the compliance officer, and probably representatives from nursing administration and senior administration [should be included, too]. One of the things every policy needs is to have the governing body’s blessing."

The composition of the group will depend on the size of the organization, Rosenblum says.

"In a hospital, the logical composition of such a task force would include a nurse, a doctor, a nutritionist — people who have direct contact with patients and are on the line being confronted on a daily basis," he continues. "You also need representatives from risk management and/or quality management or performance improvement committees, the legal counsel’s office and now, under HIPAA [Health Insurance Portability and Accountability Act], from the privacy or security office and a patient relations official. Also, in intermediate or long-term care facilities, you’d want a patient representative."

When crafting your policy, there is ample help available for at least creating its foundation, notes Stouffer. "For the bare-bones skeleton of a policy, there are guidelines about timelines to responses, and so on, on both the CMS and Joint Commission [on Accreditation of Healthcare Organizations] web sites."

Wedemeyer lists these considerations:

  • The governing body should have oversight of the process unless it is delegated to the grievance committee.
  • When a patient is admitted, he or she should receive written information about the process — how it unfolds, the process for filing, and so on. "There should be a signed acknowledgement that the patient has received this," she advises.
  • You should identify the individual within the organization whom the patient should contact with a complaint and how that contact should occur.
  • The policy should include an expectation that grievances be investigated and resolved in a timely manner. It should address time for completion of the review and investigative process, and when the patient will be provided results.
  • It should address timely referral of concerns about quality of care or premature discharge to the appropriate peer review body.

In creating your policy, Rosenblum says, special consideration must be given to certain issues that affect the hospital and staff, and to those that affect the patient and staff.

Concerning hospital and staff: "In our opinion, the provider must embrace and encourage a cultural change in staff that is similar to one that pervades all business success: The customer is always right." This should be altered slightly for health care to read: "The patient always has something useful to say," he notes.

"This should pervade good medicine," explains Rosenblum. "Every complaint represents their perception of the care they receive. This begins to preclude staff from getting their backs up. Provide workshops to help staff calmly approach patient complaints with more objective consideration for what patients have to say. This way, you help them resolve the issue or elicit their cooperation in resolving it."

Your approach should include educating and training staff on the importance of consistency, better patient relations, and mitigating harmful effects, he recommends. "Workshops that use the concept of root-cause analysis can encourage discussion of frequent complaints, their causes, and how to resolve them," Rosenblum says.

When you’re planning significant changes in service — such as a new specialty or a rapid expansion, it’s usually a good idea to perform an FMEA, he adds. "This way, you may be able to think about the potential for patient complaints and approach it proactively," he explains.

Your facility also should provide step-by-step guidance for staff on how to accept and process a complaint, identify the chain of command, and assign responsibilities.

As for patient/staff issues, the patient must know how to initiate a complaint to the provider and, when necessary and when the facility is legally obligated, how to contact a third party. There should be time restrictions for filing and an outline of what staff are responsible for doing when they receive a complaint.

"Staff could virtually be anybody — a guard at the door or someone in the medical records office," Rosenblum explains. The policy should include the forms or reports staff need to fill out and the time windows for each.

The policy also should provide patients with an explanation of their rights to appeal:

  • the process, who does the review, and who participates;
  • how to file a complaint to a third party;
  • the time window;
  • whether those authorities have the right to investigate a complaint;
  • whether there is a finding of noncompliance, those third parties may have the obligation to provide written notice to the patient.

Once the policy is created, dissemination and implementation should be carried out "just like any other policy," Wedemeyer says. "For dissemination, normally your facility has a designated method — i.e., give it to the managers, who review it with staff, who then sign a document to the effect that they have read it. The follow-up problem lies in the hands of the point person, the quality person, and possibly the compliance officer," she adds.

"You’ve got to use the existing QI staff to disseminate the information and continuously improve the process," Rosenblum stresses. "But the most important thing a provider can do is to embrace and encourage cultural change in the staff," he adds.

"We have 1,500 employees, and everyone is really an advocate for patients, so the most difficult part is getting educational information out for all of them," Stouffer says. "We cannot ignore grievances, and our response has to follow a more particular process, so we have a learning charter — a patient advocate course that talks about the service recovery program and educates employees about our grievance policy."

Every employee is required to take this course, she notes. "We also have an opportunity for on-line learning, and our policy is always available on our intranet." Just having a policy in place can have a positive effect on patient attitudes and avoid costly problems. "Primarily, it’s the perception that we have established a process that allows a patient to have a second voice with a more neutral party, if necessary," Stouffer says.

Wedemeyer agrees. "Patients are sometimes reluctant to talk about their health care, or they don’t know where to go to do it. This process gives them an avenue to do this. Also, it gives the facility a means to measure service. You can go back retrospectively or look at it concurrently, to see if it’s being followed," she says.

"Your grievance policy is just as important as a fire policy," Stouffer adds. "So if you can put policies and procedures somewhere inside mandatory training, this should be one of them."

Need More Information?

For more information, contact:

  • Matthew Rosenblum, Chief Operations Officer, Privacy, Quality Management, and Regulatory Affairs, CPI Directions Inc., 10 W. 15th St., Suite 1922, New York, NY 10011. Phone: (212) 675-6367. E-mail: MRosenblum@att.net. Web: www.CPIdirections.com.
  • James W. Saxton, JD, Chairman, Healthcare Litigation Group, Stevens & Lee, PC, Lancaster, PA. Phone: (717) 399-6639. E-mail: JWS@stevenslee.com.
  • Cathy S.C. Stouffer, Customer Service/Patient Safety Officer, Freeport (IL) Health Network. Phone: (815) 599-6356. E-mail: cstouffer@fhn.org.
  • Sue Wedemeyer, RN, BSN, MBA, Clinical Manager, Loss Prevention, Catholic Health Initiatives, Erlanger, KY. Phone: (859) 594-3076. E-mail: SueWedemeyer@CatholicHealth.net.