In 1999, the Centers for Medicare & Medicaid Services (CMS) established a hospital Patient's Rights' Condition of Participation (CoP). CoPs are the minimum health and safety standards that health care providers must meet in order to participate in the Medicare and Medicaid programs. The Patient's Rights' CoP guarantees a patient the right to receive information and requires hospitals to establish a patient grievance process.
Though in effect since 1999, the patient grievance mandate contained in the Patient's Rights' CoP essentially lay dormant until CMS published its Interpretive Guidelines. The guidelines, effective Sept. 19, 2005, define "grievance" and set forth time frames by which a hospital must investigate and resolve patient grievances. The guidelines also require hospitals to:
So why should a hospital take a new look at its patient grievance process? According to Lisa Venn, JD, MA, manager of compliance at University Hospitals in Cleveland, the reason lies in The Joint Commission's loss of statutory deeming authority. Venn says that when Congress revoked The Joint Commission's unique deeming authority in July 2008, The Joint Commission had to apply for deeming authority just like every other accreditation organization. As part of its hospital deeming authority application, The Joint Commission revised its standards and elements of performance (EPs) in an effort to demonstrate that they are equal to or stricter than CMS' Conditions of Participation. As part of the standards revision process, she says, The Joint Commission significantly overhauled its complaint resolution Standard RI.01.07.01. Now, The Joint Commission's complaint resolution standard more closely resembles CMS' patient grievance CoP. Venn notes that, while effective, these standards are presently under review by CMS.
Before the revision, The Joint Commission standards were relatively silent on the issue of the patient complaint process and hence not the focus of Joint Commission surveyors, explains Venn. "A hospital should take this opportunity to prepare for a surveyor's review of its patient grievance process," she says, noting that CMS is presently evaluating The Joint Commission's application for hospital deeming authority. Venn says that CMS will be evaluating Joint Commission surveyors out in the field to ensure that surveyors are appropriately determining hospitals' compliance with CoPs.
Venn says that every hospital may benefit from reviewing the patient grievance Interpretive Guidelines in light of the hospital's patient grievance policy and procedures. She warns against "the five stumbling blocks" of any patient complaint process:
Failure to centralize
CMS requires that the hospital's governing body take full responsibility for ensuring compliance with CMS grievance regulations. While the governing body may delegate the process to a committee, the governing body remains responsible for the committee's compliance with the grievance policy. The designated grievance committee must have adequate numbers of qualified members to review and resolve patient grievances. Venn notes that larger hospital systems often take a disjointed approach to processing patient grievances. Patient grievances may be handled by several departments, including finance, clinical risk, ombudsman, and legal.
Venn suggests that larger hospitals first centralize the grievance process. "Ideally, the governing body will select a grievance committee comprised of individuals with expertise in patient rights, hospital regulations, investigation process, and conflict management," states Venn. She also notes that because the hospital must educate staff and patients about the grievance process, grievance committee members should possess exceptional communication skills. Venn warns: "A hospital that fails to centralize the process may drop the ball and fail to timely investigate and follow up on patient grievances."
Narrowly defining 'grievance'
"Some hospitals seem to spend a lot of time deciding what is and what is not a grievance," Venn says. She explains that CMS broadly defines "grievance" to include a written or verbal complaint by a patient, or the patient's representative, regarding the patient's care, abuse, or neglect; the hospitals' compliance with the CMS Hospital Conditions of Participation; or a Medicare beneficiary billing complaint related to rights and limitations by 42 CFR § 489. Venn explains that since the CMS reference to § 489 essentially incorporates any issues regarding allowable charges to beneficiaries for deductibles, coinsurance, copayments, and services, most Medicare beneficiary billing complaints should be treated as grievances.
Venn also says that the Interpretive Guidelines state that whenever a patient or the patient's representative requests the complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, then the complaint is a grievance. "In my 15 years as a patient advocate, I have found that when a patient thinks the issue is important enough to complain about, the patient expects a response. When in doubt, hospitals should err on the side of calling a complaint a grievance."
Failure to document
CMS requires hospitals to document efforts to resolve the grievance and demonstrate compliance with CMS requirements. Venn says, "The old adage, 'If it's not in writing, it didn't happen' is particularly applicable to the hospital's efforts to resolve a patient grievance." Venn recommends that documentation should provide a detailed accounting of events to show organizational compliance to surveyors during both annual and complaint-driven surveys.
Lack of follow up
CMS mandates that in its resolution of the grievance, the hospital must provide the patient with written notice of its decision. Venn explains that, while a hospital is not required to provide an exhaustive explanation of every action the hospital has taken to investigate or resolve the grievance, CMS requires that the letter contain the following:
Venn notes that it is also "just good customer service to send a follow-up letter." She suggests that the follow-up letter be included in the hospital's process documentation.
Absence of compliance awareness
There may be hidden compliance snares for hospitals dealing with patient grievances. Venn notes, for example, that there is a great emphasis on patient service recovery when dealing with patient grievances. "Understandably, hospitals want to make the patient happy and may wish to give a gift or waive a copay," Venn states. However, she reminds hospitals that the Office of Inspector General (OIG) has issued guidelines limiting the value of service recovery gifts to $10 per gift or $50 per patient per year. She also notes that there are compliance issues related to the waiver of copayment and deductibles for patients with federal payer insurance. "I strongly recommend that the grievance committee work closely with the hospital compliance officer to stay aware of potential compliance issues."
Finally, Venn says, "A wise health care provider will embrace the grievance process as an opportunity to identify, investigate, and resolve patients' concerns. The unappealing alternative is that unhappy patients take their business elsewhere, pursue regulatory compliance options, and/or pursue litigation." Now that The Joint Commission's standards reflect CMS' patient grievance regulations, she says, a hospital has an opportunity to take a new look at its patient grievance process.
In 1999, the Centers for Medicare & Medicaid Services (CMS) established a hospital Patient's Rights' Condition of Participation (CoP).
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Financial Disclosure: None of the authors or planners for this educational activity have relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients
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