New CMS guidelines for managing complaints
New CMS guidelines for managing complaints
You’ll need system to investigate grievances
When the Centers for Medicare & Medicaid Services (CMS) issued its original Patients’ Rights Conditions of Participation (COPs) for hospitals in 1999, the definition of a "grievance" was unclear, says Patrice Spath, a Forest Grove, OR-based health care quality specialist. Now newly published interpretive guidelines from CMS attempt to clear up the confusion. The guidelines address several COPs, including patient grievances. (You can access the guidelines at www.cms.hhs.gov/medicaid/survey-cert/sc0542.pdf.)
"One area that may be problematic for hospitals is an unresolved verbal complaint," says Spath.
According to the guidelines, these are to be treated like formal grievances. This means that the hospital will need to have a mechanism for identifying unresolved verbal complaints so that the proper grievance investigation and resolution process can be initiated in a timely manner.
Your policy and procedure must give specific steps for managing an unresolved verbal complaint, says Michelle Pelling, MBA, RN, president of the Propell Group, a Newberg, OR-based health care consulting organization specializing in Joint Commission compliance and performance measurement.
Once these requirements are in the policy and procedure, staff who could be involved with an unresolved verbal complaint should receive training about the patient’s right to know that they may file a grievance, and what to do if a patient complaint cannot be resolved by the staff members, supervisors, or representatives from administration available at the time, advises Pelling.
Another issue addressed by the guidelines is the role of the hospital’s governing board. "It is no longer acceptable for the board to delegate grievance review to one individual, such as a patient advocate," says Spath.
If the board chooses to delegate the grievance review and resolution process, then it must be assigned to a committee comprised of an adequate number of qualified individuals. Although the guidelines mention a grievance committee, it isn’t necessary to form a new committee with this title, Spath says. "An existing committee, such as the Quality Council or other multidisciplinary group, could serve as the hospital’s grievance committee. Just make sure you get this in writing," she advises.
If the board delegates the grievance process, board minutes should reflect this decision and specify which group is responsible, she says.
The CMS patient rights regulations are much more detailed and stringent than the Joint Commission’s standards, Spath notes. "This is just another example of how important it is for quality managers and compliance officers to stay current in their understanding of CMS regulations as well as accreditation standards," she says.
The Joint Commission standards merely state that hospitals are to have a process for receiving, reviewing, and when possible, resolving complaints from patients and their families. "The CMS regulations contain a lot more detail about how this process should work," says Spath. "For example, according to the CMS interpretative guidelines, a timely response to patient complaints is considered to be seven days."
Quality professionals should be familiar with their organization’s policy and procedure on patient grievances, says Pelling. "The first step is to make sure that CMS’s definition of patient grievances is reflected in your policy," she says.
Your organization’s policy and procedure should clearly outline what the term "staff present" means, Pelling recommends. According to the CMS definition, this refers to any hospital staff present at the time of the complaint, or those who can quickly be at the patient’s location to resolve the complaint.
To assess whether your organization is prepared to comply with the CMS requirements, quality professionals should query staff members periodically to determine their degree of understanding, says Pelling.
She recommends querying nurses and other clinical staff monthly or quarterly about their role in addressing patient complaints, along with other questions about other procedures related to patient satisfaction, patient safety, and the provision of care. "This will support ongoing knowledge of CMS and Joint Commission requirements," says Pelling.
As a quality professional, you also should develop methods to review patient complaints to determine if they were resolved at the time of the complaint or, if not, whether the organization followed the procedure for patient grievances. Depending on the outcome, additional education and coaching may be necessary, says Pelling.
However, the quality professional’s role is to work with the individuals responsible for developing methods to assure compliance with these requirements, not to take full ownership of the process, adds Pelling.
"The quality professional’s role is that of an internal consultant and should be to guide the efforts of those who are responsible for assuring that their staff members understand and comply with the requirements," says Pelling.
[For more information, contact:
Michelle Pelling, MBA, RN, The ProPell Group, PO Box 910, Newberg, OR 97132. Phone: (503) 538-5030. Fax: (503) 538-0115. E-mail: [email protected].
Patrice Spath, RHIT, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: [email protected]. Web: www.brownspath.com.]
When the Centers for Medicare & Medicaid Services (CMS) issued its original Patients Rights Conditions of Participation (COPs) for hospitals in 1999, the definition of a grievance was unclear, says Patrice Spath, a Forest Grove, OR-based health care quality specialist.Subscribe Now for Access
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