Healthcare Compliance Forms and Tools

Scope

System-wide policy

Purpose

ABC Health System is committed to the protection and promotion of the rights of each patient who receives care and services at any ABC location. This policy has been developed to establish ABC’s process for receiving, investigating, and resolving patient, family, visitor, and physician complaints and grievances. Each patient will be clearly advised of their right to make a complaint or file a grievance in writing or verbally upon admission or registration to any service or facility within the ABC System

As part of its notification of patient rights, ABC must provide the patient or the patient’s representative the phone numbers and addresses for lodging a grievance with the State of Alabama Department of Public Health (State), The Joint Commission (TJC), and the Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO). ABC must inform the patient that they may lodge a grievance with the State, TJC, and QIO directly, regardless of whether they first used the hospital’s grievance process. At this time, all patients and/or the patient representative should be informed of ABC’s internal grievance process and how to contact a patient liaison to file a grievance. ABC must ensure that all patients are aware of their right to seek review and/or appeal by the QIO for quality-of-care issues, coverage decisions, and to appeal a premature discharge; the patient must also be informed that they may contact the QIO to lodge a complaint. Patients, family members, significant others, and visitors to ABC are encouraged to promptly express their concerns to hospital personnel.

Efforts will be made to resolve concerns at the time they are reported by staff that is present. If that is not possible, concerns will be referred to the department manager, designated patient liaison, or the administrative supervisor for investigation and resolution. If the patient liaison (or designee) is unable to resolve the matter to the satisfaction of the complainant, a Grievance Review Committee meeting may be convened to review and rule on the issue. All complaints received will follow the principles of complaint management: Assessment, Investigating, Response, Documentation, Trending Analysis, and Reporting for quality improvement purposes.

Policy

ABC is committed to meeting or exceeding our customers’ expectations of care and service. Providing quality service is the responsibility of every ABC employee. All employees are expected to participate in the complaint and grievance resolution process by adhering to service recovery principles and following the guidelines outlined herein. It is the policy of ABC that complaints, grievances, and/or concerns from patients and/or family members are investigated and answered in a confidential and timely manner. Effective and prompt resolution of complaints and grievances are key factors in achieving excellent customer service. ABC’s customers are encouraged to express their concerns without fear of retaliation or fear of their care being compromised. Every member of the ABC health care team plays a vital role in supporting patients toward optimal health. Each employee should make every effort to resolve the patient’s concerns and grievances within their authority or scope of practice that falls within their credentials.

The patient liaison is responsible for the effective facilitation of the complaint/grievance process and for conducting and/or coordinating the review and resolution of complaints/grievances except for those complaints/grievances relative to quality, privacy, or risk management. All patients and guests should be assured that their complaints will be investigated and resolved in a prompt, reasonable, and consistent manner. Complaints and grievances will be entered into MIDAS Patient Relations Module, which is the compliance database. Data collected regarding patient complaints and grievances, as well as some other complaints that are not defined as grievances (as determined by the hospital), must be incorporated into the hospital’s Quality Assessment and Performance Improvement Program (QAPI). Complaints and grievances received after business hours, on weekends, and during holidays will be handled by the administrative supervisor, who will act as the coordinator for the complaint and grievance management process in the absence of the patient liaison. The administrative supervisor should enter all feedback into MIDAS, and patient liaisons should be notified of such complaints by the next business day if needed.

Definitions

1. A “compliment” for purposes of this policy includes:

   1. Any comment that commends the organization or individual associated with the organization.

2. A “complaint” for purposes of this policy includes:

   1. A concern or complaint regarding hospital services or patient care expressed by the patient or patient representative that can be resolved at the point of service by staff present.

   2. A post-hospital-stay verbal communication regarding hospital services or patient care that would have been routinely handled by staff present if the communication had occurred during the hospital stay or visit.

   3. A relatively minor issue that can be resolved quickly by the person receiving the information and does not require intervention by management or the patient liaison (e.g., change in bedding, housekeeping of a room, diet or serving preferred food and beverage, parking, lost and found issues) that can be addressed by staff present and promptly resolved to the patient’s satisfaction.

   4. A concern expressed to administration or patient liaison prior to attempting to resolve the matter with the staff present at the time of the incident.

   5. A concern or complaint first made known to administration or patient liaison via a written survey or comment card but not made known to the staff during the stay or visit. Information obtained from patient satisfaction surveys usually does not meet the definition of a grievance.

   6. A billing issue that does not include patient quality of care issues or Medicare beneficiary complaints relative to rights and limitations provided by 42 C.F.R. § 489 .

   7. A privacy issue or an issue involving use or disclosure of protected health information (PHI) that does not include patient quality of care issues.

3. A “grievance” for purposes of this policy includes:

   1. A “patient grievance” is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present), abuse or neglect, patient harm, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitation provided by 42 C.F.R. § 489 .

   2. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires further investigation, and/or requires actions for resolution or coordination with other hospital departments, then the complaint is a grievance for the purposes of this document.

   3. A written complaint is always considered a grievance. A complaint communication in writing (letter, fax, or email) that may come in from an inpatient, outpatient, released/discharged patient, or a patient’s representative regarding the care provided, abuse and neglect, or the hospital’s compliance of CoPs. For the purposes of this requirement, an email or fax is considered “written.”

   4. Any complaint that is requested by the patient or a patient’s representative to be handled as “formal complaint,” and the patient has requested a response from the hospital.

   5. When an identified patient/patient representative writes or attaches a written complaint to a patient satisfaction survey or comment card and requests resolution, the complaint meets the definition of a grievance. If an identified patient writes or attaches a complaint to the survey or comment card but has not requested resolution, ABC must treat this as a grievance if it would usually treat such a complaint as a grievance.

   6. Any complaint, whether verbal or written, where a patient or patient representative complains regarding quality of care, disagrees with a coverage decision, or wish to appeal a premature discharge is a grievance. In the event that this occurs, the patient or patient representative may contact the QIO to lodge a complaint along with following the hospital’s internal grievance process. ABC is required to have procedures for referring Medicare beneficiary concerns to the QIOs; additionally, CMS expects coordination between the grievance process and existing grievance referral procedures so that the beneficiary’s complaints are handled in a timely manner and referred to the QIO at the beneficiary’s request.

   7. Patient complaints that are considered grievances also include situations where a patient or patient representative telephones the hospital with a complaint regarding the patient’s care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements. Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a grievance.

   8. Any complaint or concern thought to have been resolved that returns to the administration or patient liaison as unresolved to the patient’s satisfaction escalates to a grievance.

   9. Billing issues where the patient/patient representative states they will not pay because of care or treatment issues.

   10. Any concern or complaint filed directly with a regulatory agency, the State, TJC, or CMS.

   11. Any complaint determined by the patient liaison to be serious enough to warrant the review of the Grievance Committee.

   Note: It is not a grievance by CMS’s definition if the patient is satisfied with the care but a family member is not.

4. “MIDAS Patient Relations Module” for purposes of this policy include:

   The electronic system used to document, manage, analyze, track, and report feedback from our patients, families, visitors, and physicians. All feedback is entered into MIDAS or sent to a centralized contact (i.e., patient liaison) where it is recorded and sent to the appropriate department for action and resolution. Once the issue has been resolved, the information will be sent back to the patient liaison for review and closure of the patient’s file.

5. “Resolution” for purposes of this policy includes:

   A complaint or grievance is considered resolved when the complainant is satisfied with the actions taken on the patient’s behalf or the hospital has taken all reasonable and appropriate steps to resolve the matter, even though the patient or patient representative remains unsatisfied.

6. “Staff present” for purposes of this policy includes:

   “Staff present” includes any ABC staff that is present at the time of the complaint or who can quickly be at the patient’s location that can assist with resolving the patient’s concern or complaint (i.e., this includes, but is not limited to, physicians, nurses, administrative staff, nursing supervisors, patient liaisons, and other staff.)

7. “Patient representative” for purposes of this policy includes:

   An adult authorized by a competent patient’s verbal or written consent to be their representative. An adult with legal authority to make health care decisions on behalf of an incompetent patient is also called a surrogate. An adult appointed by the patient