Part 1 of a 3-part Series

When does a complaint become a grievance?

How to strengthen your patient grievance process

By Patrice Spath, ART

Brown-Spath Associates

Forest Grove, OR

Included in the new Conditions of Participation (CoPs) issued by the Health Care Financing Administration (HCFA) is the requirement that a hospital’s governing board ensure that there is a well-defined process that patients can use to file grievances and receive feedback.1 Notifica tion of the grievance process must be provided to patients along with other statements of their rights. Even if your hospital already has a patient grievance process, it may need to be changed or strengthened. The CoPs allow hospitals a lot of latitude in meeting the grievance process requirements. Nonetheless, the standards do require that certain elements be in place. This article is the first in a three-part series about how to comply with HCFA’s standards for patient grievance processes. This month, we cover the first critical question you need to ask: What is the difference between a complaint and a grievance?

The CoPs do not offer a definition for the term "grievance." Thus, the regulations are unclear and could be interpreted to include clarification requests or voiced concerns that can be resolved informally. Until HCFA issues Interpretive Guidelines for this aspect of the patients’ rights standards, it will be up to the individual facility to sort out the difference between patient complaints and grievances. Existing federal regulations that govern the health care industry may provide some insight into how hospitals can differentiate between complaints and grievances.

HCFA requires peer review organizations (PROs) to respond to patient complaints about quality of care at Medicare-participating providers. The complaints must relate to a Medicare-reimbursable service. The purpose of the PRO’s review of patient complaints is to judge whether or not the complaint is valid. To determine the validity of a beneficiary’s complaint, the PRO evaluates the service to see if it meets professionally recognized standards of health care, including appropriateness of care and adequacy of access.

The terms complaint and grievance both appeared in HCFA’s Guidelines for Implementing and Moni toring Compliance with Quality Improve ment Standards for Managed Care (September 1998). However, HCFA made it clear that the standard does not distinguish between "formal" and "informal" grievances, or between "grievances" and "complaints." For the purpose of the patient rights standards that apply to federally funded managed care organizations, a grievance is defined as any communication, oral or written, from an enrollee to any employee of the organization or of its providers, expressing dissatisfaction with any aspect of the organization’s or provider’s operations, activities, or behavior, regardless of whether any remedial action is requested.

The Interpretive Guidelines for this standard also provide some examples of possible subjects of grievances. These include complaints about the quality of services provided; complaints about interpersonal aspects of care, such as rudeness by a provider or staff member; and failure to respect any of the enrollee’s rights. Many states have adopted similar regulations for all health plans. In state regulations, the term "grievance" generally applies to appeals made for service coverage denials. Other concerns would be classified as complaints.

The patient grievance process in the new CoPs arose from recommendations made in 1997 by the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry. However, the Consumer Bill of Rights and Respon sibilities promulgated by this Commission uses the term "complaint" rather than "grievance."

A complaint, according to the President’s Commission, is "any expression of dissatisfaction to a health plan, provider, or facility by a consumer made orally or in writing. This includes concerns about the operations of providers, insurers, or health plans, such as waiting times, the demeanor of health care personnel, the adequacy of facilities or the respect paid to consumers, and claims regarding the right of the consumer to receive services or receive payment for services previously rendered, including the organization’s refusal to provide services the consumer believes he or she is entitled to."2 It seems evident that federal and state regulators use the terms "complaint" and "griev ance" indiscriminately and sometimes synonymously, whereas the President’s Commission did not use the term "grievance" at all.

Don’t rely on a statement such as, "a complaint becomes a grievance at the point it is reduced to writing and submitted to the appropriate authorities," or your hospital may find itself investigating a lot of grievances that are really only questions about the bill or service concerns that could have been handled informally. While formal patient grievances could be filed about the hospital’s billing practices, the patient rights standard in the CoPs most likely refers to complaints about quality of care, denied access to care (e.g., premature discharge, failure to order diagnostic studies, etc.), or violations of personal rights. Also remember that the CoPs allow patients to make verbal grievances, so be sure your definition is not limited to written notices.

Sample definitions for a complaint and a grievance are shown in the box on p. 14. These definitions focus on quality of care issues, rather than billing or other administrative issues. These definitions can serve as a starting point for hospitals seeking to develop their own definitions. Remember to watch for HCFA’s release of Inter pret ive Guidelines, as they may provide more guidance about the exact nature of grievances. As of now, hospitals will best be served if they develop a definition for grievances that meets the original intent of the Consumer Bill of Rights and Responsibilities.

How formal is the process?

The factor that distinguishes a complaint from a grievance is the formality of the process. In a grievance situation, the patient (or the patient’s representative) is specifically requesting that his or her complaint undergo a formal (and therefore well-defined) review process. This request may follow a complaint that was not resolved to the patient’s satisfaction, or the request for a formal review may be the first step a patient takes when he is dissatisfied.

It will be important to inform patients that they have several avenues for voicing concerns, and filing grievances is not the only mechanism to ensure they receive satisfactory responses. Many hospitals already have a statement in the listing of patients’ rights that lets people know a formal grievance process is available. However, patients also should be notified that voicing their concerns directly to caregivers or other hospital staff can, in most instances, resolve the problem quickly and effectively without the need for a more formal review.

Next month’s "Quality/Cost Connection" column will describe the patient grievance process and offer hospitals practical recommendations for meeting the intent of the CoPs.

[Editor’s note: A copy of the "Consumer Bill of Rights and Responsibilities" is available on the Web site of the Presidential Advisory Commission on Consumer Pro tec tion and Quality in the Health Care Industry. Address: www.hcqualitycommission.gov. To obtain a printed copy of the report, call (800) 732-8200, or write to Consumer Bill of Rights, Box 2429, Columbia, MD 21045-1429.]

References

1. Medicare and Medicaid Programs. Hospital Conditions of Participation: Sec. 482.13, patients’ rights (issued July 2, 1999).

2. President’s Advisory Commission on Consumer Protection and Quality. "Consumer Bill of Rights and Responsibilities." Washington, DC: July 1998, chapter 7.