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February 21, 2005

What’s Your Complaint Policy?
(Ignoring Them Is a Bad Answer)
By Patrice L. Spath, BA, RHIT
Radiology Today
Vol. 6 No. 4 Page 26

A formal complaint process is both a regulatory requirement and an excellent way to improve service quality. An expert shares advice on how healthcare organizations can build a better grievance policy.

Patient complaints could cause an imaging department or facility to lose future business from both the person complaining and the physician who referred the patient. Besides the strictly financial issues, complaints are vital sources of performance information.

Managing complaints is also required by both the Medicare Conditions of Participation (COPs) and JCAHO standards. With all that in mind, an effective complaint-handling system becomes an important part of every radiology facility’s quality control system.

The terms complaint and grievance are often used interchangeably to describe either formal or informal criticisms voiced by patients. These criticisms may address any aspect of healthcare delivery, including the quality of services provided, interpersonal aspects of care, or individual rights issues.

Some healthcare organizations choose to distinguish complaints from grievances. For example, a complaint may be defined as a written or verbal concern or objection regarding the quality or appropriateness of patient care that can be effectively addressed and resolved by informal means. Many complaints can be handled quickly and effectively in this informal manner.

A grievance can be defined as a written or verbal request by a patient or his or her designated representative to have the facility formally review their concern or objection about the quality or appropriateness of patient care. In a grievance situation, the patient (or his or her representative) is often 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 or she is dissatisfied.

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

The Medicare COPs and the JCAHO standards allow healthcare facilities plenty of latitude in handling grievances and complaints. However, to meet Medicare requirements, the grievance procedure must be explicit and meet the following requirements:

• provide patients with the name of the hospital representative who should be contacted to file a grievance;

• set specific time frames for review of the grievance and the provision of a response;

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

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

• provide a mechanism for appeal if the patient is not satisfied with the outcome of the grievance investigation.

Building a Process
The final responsibility for resolving patient grievances lies with the organization’s board of directors. However, board members must rely on the recommendations of the people involved in investigating the grievance. In many instances, it is best for the board to delegate the operational aspects of the grievance process to a multidisciplinary committee. However, the governing board should make sure the organization has a clearly defined and impartial process for resolving patient grievances. The Medicare COPs require a grievance process, but it is also an important aspect of quality customer service. The grievance procedure should encourage open communication between patients and facility staff. Patients must be offered assistance in formulating and submitting grievances and timely resolution of problems.

Most complaints may be more effectively addressed and resolved by informal means, but it must be made clear to patients that they have the right to have their concerns heard by upper management.

It is fairly common for providers and health plans to have a two-stage process for handling grievances. The first stage typically involves a few decision makers in the review. If patients are dissatisfied with the outcome of the first-level review, they can take their complaint to a second stage involving the grievance committee. Adapt your grievance process to your organization’s size and complexity. While smaller facilities may not have the same resources to devote to handling grievances as larger facilities, their customer service performance will improve from dealing effectively and efficiently with complaints that arise.

Whenever possible, 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. Because physicians and staff members are usually the first point of contact for patients, make sure they have an understanding of the organization’s grievance procedures.

Ideally, any person in the organization can initiate the grievance process and help the patient figure out how to file the complaint. Develop written procedures and train staff how to receive and initiate the grievance process. These procedures should include the form patients can use to make their complaint and the name of the organization representative who will coordinate the grievance investigation. (A sample grievance form is shown in Figure 1.) The facility person who coordinates the grievance process may be the patient advocate, quality manager, risk manager, or another person designated to fulfill this role.

Complaint Triage
When the facility receives a grievance or complaint (either oral or written), several determinations must be made by the grievance coordinator. First, can the issue be quickly resolved without the need for a formal investigation? A formal grievance procedure might not be necessary to solve the problem. However, even if an informal solution satisfies the patient, his or her concern and the resolution should be recorded on a complaint log to preserve information for internal performance measurement functions.

The grievance coordinator must also determine ownership of the grievance. For example, the patient may have a valid complaint, but the criticism deals with something outside the provider’s control—a technologist may field a complaint about insurance coverage or referral problems completely outside the tech’s control. In these instances, the patient should be counseled on where his or her complaint should be directed. It is important to offer patients assistance in filing a grievance with the correct agency or organization.

If the grievance can’t be resolved informally or is of such a magnitude that the full process must be implemented, the facility representative then acknowledges receipt of the issue and explains to the patient the process that will be followed in investigating the complaint. If the patient is currently receiving care in the facility, this explanation can occur in person, but the patient must also receive a written notice. If the patient has been discharged, send a letter explaining the grievance process. The written notifications 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 and responsibilities at each step. Include an offer to assist the patient as needed in completing forms or taking other necessary steps in the notice.

Other Options
Also inform the patient of additional methods for resolving the issue that are external to the provider’s own process. For example, Medicare patients have the right to submit a quality-of-care complaint to the state Quality Improvement Organization (QIO). Issues of insurance coverage and nonpayment can be presented to state agencies such as the Insurance Commission. These external mechanisms supplement but do not replace your facility’s grievance process. If the person with the grievance is a Medicare patient concerned that his or her doctor is discharging him/her from the hospital too soon, the facility should make sure that the state QIO is aware of the grievance. Also, the facility should offer to help the patient or his or her representative request an immediate review from the QIO.

Patients may feel uncomfortable approaching a health plan or another provider with a complaint; the treating facility should assist people in making their concerns known. Some organizations provide patient advocate or ombudsman services to assist patients and their families with any concerns related to the healthcare experience.

If the grievance needs to be reviewed and resolved by the facility, the people to be involved in the initial review of the complaint must be identified. Grievance resolution must be timely, and holding a grievance committee meeting for every formal complaint may delay the process. It is especially important that formal complaints about quality of care or premature discharge be resolved quickly, although radiology departments rarely face discharge issues.

Tiered System
To meet process goals, most facilities have a first-level review process that involves a small group of individuals that evaluates the situation and makes a determination about how to resolve the situation. This first-level evaluation group may include the patient advocate or the person charged with overseeing the grievance process, the CEO or his or her designee, and the director of the department involved in the complaint. If the grievance is about the quality of care provided by physicians or a discharge decision felt to be improper by the patient, the medical director or physician chief of service is included in the first-level review.

If the grievance represents an immediate and serious threat to patient health and safety, the organization must have an expedited first-level grievance review process. Otherwise, the first-level review group should meet within the time frame defined by the organization’s policies (generally no later than 10 days after the grievance is received). Committee members must be provided with adequate time to review relevant details about the situation before meeting. At the first-level review meeting, the group is provided sufficient information to be able to decide how to handle the grievance. The group is authorized to resolve a grievance in any manner it regards appropriate, as long as it does not exceed the organization’s lawful authority. If the first-level review group is unable to reach a decision, it may recommend that the issue be forwarded to a grievance committee comprised of broader representation.

Second-Level Review
Most grievances can be resolved in the first-level review process. On rare occasions, a grievance committee may need to be appointed to resolve first-level review deadlocks or when the person with the grievance requests reconsideration of the initial decision. The facility’s leaders decide which departments and disciplines serve on the second-level review committee. If the organization has an ethics committee, this group could be charged with investigating and rendering second-level decisions on complaints. If the organization lacks a formal ethics committee, a grievance committee can be established as task force of the governing board.

The grievance committee members should be different people than those who initially reviewed the grievance. Make sure that the members of the grievance committee have no actual or apparent bias or conflict of interest. Examples of conflicts of interest include people who will potentially benefit or lose from a decision and anyone who has previously been involved in any attempted resolution of the complaint.

One problem with many complaint investigation procedures is the perceived lack of impartiality. A dissatisfied patient does not expect or want the same people whom he or she is complaining about to be the one deciding the complaint’s validity. The facility may encourage the patient or his or her representative to appear in person before the grievance committee to state his or her case. It can be helpful to include as a grievance committee member someone from the clergy and/or a community representative who is not affiliated with the organization in any way. The committee can ask other people to provide information pertinent to the complaint. Such information may be provided in person or in writing. All parties should be given a full and fair opportunity to respond to all information gathered by the committee.

When grievance committee members are satisfied that they have adequate information, a consensus decision is reached. If the committee is unable to arrive at a decision, a new grievance committee may be formed to rehear the dispute or the issue can be forwarded to the governing board for final resolution.

The Organization’s Response
After reaching a decision, the grievance committee provides a written response to the patient who initiated the complaint. This response includes a restatement of the issue under inquiry, the date the review process was completed, steps taken to investigate the complaint, the review group’s final decision, and any corrective actions the facility may be implementing. If the issue involves quality of care or premature discharge, be sure to remind the patient of other avenues available to address concerns, such as state regulatory agencies, QIOs, and Medicare. Remember to provide a phone number and address for each group mentioned in the letter.

The response letter also explains the process for reconsideration if the complaining patient is dissatisfied with the results of the investigation and proposed solution. The organization may wish to provide opportunities for further consideration or may determine that its decision is final at this point. Be sure that the information provided to patients includes a clear description of the number of reconsiderations that are allowed. Generally, facilities allow only one reconsideration unless the patient can show evidence of bias or procedural irregularities, or if previously unavailable information comes to light.

Your process should include a mechanism for tracking each grievance until its final resolution. Management must designate someone responsible for monitoring the grievance review process to completion within the time frame specified in the organization’s grievance procedures. The same person should regularly report to the board the status of all grievances received, actions taken, committee recommendations, and the status of corrective action plans.

Since the implementation of HIPAA, the public has grown increasingly aware and concerned about the protection of patients’ rights. Healthcare organizations are responding by implementing a fair and impartial grievance process and complaint mechanism. Whatever procedure is used to handle grievances and complaints, it’s paramount that patients believe that they can bring up concerns without fear of discrimination or reprisal. From a patient’s viewpoint, only three things matter if something goes wrong with the service provided and he or she therefore needs to complain:
• how to complain;
• where to complain; and
• whether or not the complaint will be taken seriously.

Patients and their families will assess an organization’s seriousness in dealing with complaints by the extent to which the system is visible, accessible, and fair. Visibility depends on whether the organization has made patients and families aware of the structure and process used to deal with complaints or grievances. Develop and share with patients a short complaint policy that outlines how your organization deals with their concerns. Accessibility hinges on patients and families knowing to whom a complaint should be made and that caregivers know how to handle complaints and serious grievances. Fairness means that the organization’s leaders make sure that all complaints and grievances are properly investigated in an unbiased fashion.

— Patrice L. Spath, BA, RHIT, is a healthcare quality specialist, editor of Partnering with Patients to Reduce Medical Errors, and a partner in Brown-Spath & Associates (www.brownspath.com). She may be reached at Patrice@brownspath.com.

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