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Hospital patient advocates should review written policies on handling patient grievances

July 20th, 2018 | Posted in Uncategorized

If you are a patient advocate working for a hospital, become thoroughly knowledgeable about your organization’s policy for handling patient grievances and follow it, otherwise your facility could face a citation from a CMS surveyor.

In February, a hospital in West Virginia was cited under a Medicare Condition of Participation (CoP) regarding patient rights to notice of a grievance decision. A review of six complaints from a patient or the patient’s representative handled by the hospital showed no notice of the complaint resolution was provided, as required by written hospital policy, for any of them.

The CMS deficiency report citing Tag A-0123 specifically highlighted one instance involving the hospital patient’s advocate, who apparently did not know the policy.

“An interview was conducted with the facility’s Patient Advocate on 2/28/18 at 8:40 a.m. She stated: ‘I didn’t realize I had to send a letter to inform the complainant of the findings after the investigation was completed.’ When asked if she had provided a written response to the patient representative complaint dated 2/6/18, which was resolved on 2/12/18, she stated, ‘No, not yet,’” according to the deficiency report available on

The hospital’s policy on “Patient Family Grievance,” according to the report, states in part: “If a patient or patients’ representative wishes to file a formal or informal written or verbal complaint to the hospital regarding patient care, once the issue has been resolved, the Patient Advocate shall provide a timely written response whether a letter or a copy of the grievance resolution form to the patient/resident and/or family member.”

CMS requirements for notifying patients of their rights and handling grievances are set out in Medicare’s interpretive guidelines for hospital surveyors, found in State Operations Manual, Appendix A, under tags A-0118 through A-0123, says Sue Dill Calloway, RN, Esq., AD, BA, BSN, MSN, JD, CPHRM, CCMSCP, president of Patient Safety and Healthcare Consulting and Education in Dublin, Ohio.

“The consumer advocate or patient advocate is employed by the hospital but their job is to make sure that the hospital is doing the right thing and addressing patient concerns, grievances, and complaints and trying to resolve them in a positive way,” says Calloway. That includes following CMS requirements.

For years, the patient grievance process has been getting more and more scrutiny by CMS, as well as accrediting organizations such as The Joint Commission, focusing on how hospitals are handling patients’ rights at-large.

Here are some tips experts offered to DecisionHealth reporter Stephen Dashiell in Inside the Joint Commission, a partner publication to Patient Advocate Report, in a 2015 article about how to keep patient complaints from escalating to a formal grievance:

  • Listen to your patients. Often, a patient’s main concern after a complaint is that it never happens to anyone else, says Lynn Reede, CRNA, DNP, MBA senior director of professional practice at the American Association of Nurse Anesthetists (AANA). “You have to demonstrate that you care.”

If the initial provider with whom the complaint was lodged cannot immediately follow up with the patient at the time of the complaint, that provider should hand off the patient and family to a manager or director and express a desire to fix the problem, adds Lorraine Jordan, CRNA, Ph.D, FAAN, executive director of programs and research with the AANA Foundation. “Identify the experience a patient wants.”

  • Invite patients to be part of the process. Though CMS requires hospitals to identify the grievance process to the patient, as well as provide a written response to the grievance, invite them to be a part of the grievance and improvement process, advises Reede. “Engage those patients, even if it can’t be face to face. Come back to them with what your team did during debriefing.” Even if the patient is seeking something harsh such as terminations, you want to let them know that the facility reviews such measures as part of the process. “Follow up with the patient continuously.”
  • Set reasonable expectations. “You have to understand what the patient expectations are when they enter the facility and you have to let them know if those expectations are realistic or not,” says Jordan, “like a request for gourmet food.” This can help cut down on unnecessary and frivolous complaints, Jordan notes.
  • Pay heed to cultural differences. Remember that diverse cultures require diverse approaches to care and communication. Education and open communication can help prevent making unintentional mistakes that may displease the patient, or worse, says Reede.
  • Consider a second level of grievance response. If your grievance resolution process is not sufficient in resolving the patient’s concerns, consider a second-tier of grievance resolution, says Beth Hepola, director of regulatory readiness and emergency preparedness at the Colorado-based Centura Health system. This should be an independent review done by the CEO or a separately appointed grievance committee — a party who was not involved in the initial investigation. This may help provide a sense of impartiality and fairness to the patient. However, the second review must be truly independent, warns Hepola, or your hospital will not benefit from the second opportunity. — A.J. Plunkett (