Part 2 of a 3-Part Series

How to formalize your grievance response

Procedure should spell out time frames for action

By Patrice Spath, ART

Brown-Spath Associates

Forest Grove, OR

The Medicare Conditions of Participation (CoPs) require that hospitals have a process for handling patient grievances. In last month’s column, the definition of a grievance was discussed. It is clear that hospitals must carefully describe the difference between an informal complaint and a grievance. Otherwise, the formal review process may be triggered more often (or less often) than it should be.

The governing board is responsible for ensuring the grievance process is prompt and effective. The grievance procedure must be explicit and include the elements required by the CoPs. It is unlikely that the mechanism used in many facilities to handle patient complaints is as well-defined as it needs to be to meet the CoP requirements. A grievance procedure must include the following elements:

1. name of the hospital representative the patient should contact to file a grievance;

2. specific time frames for review of the grievance and the provision of a response;

3. a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate peer review organization;

4. a provision for notifying the patient of the results of the grievance review — the notification must be made in writing and include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion;

5. a provision for appeal if the patient is not satisfied with the outcome of the grievance investigation.

This month’s column will describe the first steps in the grievance process, when a grievance is filed and the hospital responds.

Whenever possible, the hospital should try to resolve patient questions or concerns quickly and informally. If this is not possible, patients must be afforded the opportunity to file a formal grievance. It is essential that physicians and hospital staff who may come into contact with patients understand the basic grievance procedures, as they may be the first point of contact for patients.

Ideally, any member of the hospital staff can start the grievance process and help the patient figure out how to file his or her complaint. Written procedures should be developed to explain how to receive and initiate the processing of grievances. These procedures should include the form patients can use to make their complaint and the name of the hospital representative who will coordinate the grievance investigation. (A sample grievance form is shown on p. 24.) The hospital person who coordinates the grievance process may be the patient advocate, quality manager, risk manager, or another person designated to fulfill this role.

Is a formal grievance really needed?

When the hospital receives a grievance (either oral or written), several determinations need to be made by the grievance coordinator. First, can the issue be quickly resolved without the need for a formal investigation? The dissatisfied patient may not have known what to do in a particular situation, and a formal grievance may not really be needed to get the problem solved. However, even if the complaint is informally resolved to the patient’s satisfaction, the issue and its resolution should be recorded on a complaint log so that information on the volume and nature of patient complaints is available for internal performance measurement functions.

Next, the person who receives the grievance must determine if the hospital is the right organization to investigate the grievance. The patient may have a valid complaint, but the issue may deal with something outside of the hospital’s control, e.g., insurance coverage, problem with another provider, etc. In these instances, the patient should be counseled about where the complaint should be directed. Be sure to offer the patient help in filing the grievance with the correct agency or organization.

If the grievance is one that should be handled by the hospital, then the grievance process is initiated. The hospital representative should acknowledge receipt of the issue and explain to the patient the process that will be followed in investigating the complaint. If the patient is currently in the hospital, this explanation can be given in person, but the patient also should receive a written notice. If the patient is no longer hospitalized, send a letter explaining the grievance process steps. The written notifications should provide a clear explanation of how the grievance will be resolved, describing each step in the process, the time frame for each step, and the patient’s rights or responsibilities at each step. Include in the written notice an offer to assist the patient as needed in completing forms or taking other necessary steps to achieve resolution of the issue.

Be sure to inform the patient of any additional methods for resolving the issue external to the hospital’s own process. For example, Medicare patients have the right to submit a quality of care complaint to the state peer review organization. Medicaid patients can present issues of coverage and nonpayment to the state agency. Some states have issue-resolution mechanisms that are available to enrollees of commercial insurance maintained by the Insurance Com mis sioner or another state agency. These external mechanisms supplement, but do not replace, the hospital’s grievance process. If the grievant is a Medicare patient and she is concerned that her doctor is discharging her too soon, make certain that the state peer review organization (PRO) is aware of the grievance. Also, offer to help the patient or her representative request an immediate review from the PRO.

Define time frames

The hospital’s procedure for handling grievances should include time frames that spell out how quickly each step will occur. Ideally, acknowledgement letters should be mailed to discharged patients within three working days of receipt of their grievance. Hospitalized patients should be visited as soon as possible. Many hospitals try to complete the initial grievance investigation process within 10 business days. At the time this article was written, the interpretive guidelines for the patient griev ance regulations issued by the Health Care Financ ing Administra tion had yet to be published. Once these are available, hospitals should consult these guidelines to determine if HCFA has established time limits for each step in the resolution of a complaint or grievance. Interpretive guidelines are usually posted on the HCFA Web site, which is located at www.hcfa.gov.

It is not uncommon for providers and health plans to have a two-stage process for handling grievances. The first stage involves only a limited number of decision makers in the review. If patients are dissatisfied with the outcome of the first-level review, there is a second stage involving a Grievance Committee. The last installment of this three-part series, appearing in next month’s issue of Hospital Peer Review, will describe this two-stage grievance mechanism.