HCFA finalizes COPs with grievance guidelines
HCFA finalizes COPs with grievance guidelines
Some see creative opportunities for hospital policies
Just in time for the dog days of summer come new Health Care Financing Administration (HCFA) guidelines on Conditions of Participation (COPs) for hospitals receiving Medicare payments.
The new guidelines are focused for now on patients’ rights and the revised section proposed in December 1997. The six standards addressed include:
• notification of rights;
• exercise of rights;
• privacy and safety;
• confidentiality of patient records;
• restraint for acute medical and surgical care;
• seclusion and restraint for behavior management.
Many quality and risk managers will be interested in the grievance standards and the accompanying surveyor guidelines.
"When it comes to grievances, I think a lot of people are sitting on the fence," says Fay A. Rozovsky, JD, MPH, president of the Rozovsky Group in Richmond, VA. "Some hospitals write off the grievance portion of the co-pay on the patient’s bill. But HCFA is uncomfortable with this arrangement. How can it do a medical review of something that’s been written off?
"There’s also the fact that write-offs may be a motivator to avoid reviews and reports of grievances," she adds. "The practice could be seen as an abuse of the system unless the practice of dealing with the co-pay is separate from the grievance review itself."
As of Aug. 1, 2000, "the grievance process must specify time frames for the review of the grievance and the provision of a response," HCFA says.
"This means hospitals need to develop policies dealing with grievances," says Rozovsky.
Surveyors will look for paperwork documenting review, investigation, and resolution within a reasonable time frame for each patient’s grievance. But HCFA stops short of defining that time frame.
HCFA also wants surveyors to determine "the extent to which the hospital initiates activities that involve the patient or the patient’s legal representative in the patient’s care."
"I think it’s not as straightforward as it appears," says Rozovsky. "The grievance could be regarding a sentinel event, in which case the quality or risk manager has the dilemma of whom to report to first. Does he or she need to call the medical examiner, the hospital administrator, the coroner? Suppose those authorities want to examine the medical equipment involved. That ties up the hospital’s investigation of the incident and delays the reporting and documentation."
In fact, the guidelines regarding grievances seem particularly vague. There are few specific details about grievance procedures. The guidelines seem to leave it up to the individual hospital to come up with policies, procedures, and time frames.
"HCFA does not dictate details about grievance procedures, fees to charge for providing records to patients where prices are not established by law, or the content for emergency protocols for the use of restraints in behavior management," according to Rozovsky.
For example, the regulation states that "the grievance process must specify time frames for review of the grievance and provision of a response."
In the guidelines for surveyors, it’s suggested that "the hospital must review, investigate and resolve each patient’s grievance within a reasonable time frame." But it adds, "grievances about situations such as neglect or abuse should be reviewed immediately."
Rozovsky theorizes that HCFA may be giving hospitals the opportunity to be creative in responding to the new standards. If so, this could be considered a plus for many hospitals. Instead of having implementation steps dictated to them, institution staff can decide for themselves how best to make changes that will help with credentialing matters.
Kristen Burkette, senior director of quality assessment for Exempla Healthcare in Denver, says Exempla is developing a program called "Voice of the Customer." The program is recruiting volunteers to make rounds of all patients, asking if everything is all right, if there are problems that should be addressed, and if they need services they don’t feel they’re getting.
"This would give us a heads-up if there is a problem for a patient," Burkette explains. "If they do have a problem and leave the hospital without saying anything, the issue begins to simmer. This is what often leads to a grievance filing."
Burkette adds that one of the first things to determine is what you’re dealing with: a complaint or a potential grievance. "Our goal is to look at each complaint and stop it from becoming a filed grievance. Sometimes the service level doesn’t meet their expectations. We discuss it with them to be sure they understand. Sometimes it’s necessary to get a physician involved."
Rozovsky says most hospitals will be fine-tuning their existing processes. For others, a greater degree of change may be necessary to prepare for the interim regulation. She recommends that all hospitals document a paper trail for grievances. Make sure there is a process for recording that patient notification took place. Also, hospitals should evaluate their patients’ rights and grievance materials. Use focus groups to determine if the format, content, and comprehension level of these materials are acceptable. If necessary, fine-tune the material to make it more user-friendly.
Burkette says Exempla is fastidious in its follow-through system regarding complaints. "We document every step of a complaint and include the closure with family and patient to make sure surveyors are aware of every step we’ve taken."
Noncompliance could result in decertification
Hospitals nationwide will be scrambling to comply with the new guidelines, of course. And if a hospital fails to meet compliance standards, it’s not a pretty scenario.
"If a hospital is in noncompliance with federal regulations, it could be decertified or subjected to further investigation," Rozovsky warns. "Surveyors may feel that if you’re not in compliance in one area, it may be only the tip of the iceberg. What else are you hiding? Is there more to this than meets the eye? In this case, they could bring in the Fraud and Abuse Control Team with 14 agents looking at every aspect of compliance situations. It would be very stressful and difficult for the hospital.
"But," Rozovsky cautions, "we can’t look at this uni-dimensionally. We also have to respect patients’ rights to confidentiality."
She suggests that when developing a policy on guideline compliance, the hospital should include all relevant people or departments. Essentially, these would be corporate compliance administrators, risk managers and quality managers, legal counsel, and consumer and patient advocates.
Rozovsky also says hospitals should look at the rules as a blueprint rather than an impediment. "The key," she says, "is to set a positive rather than negative environment for creative thinking."
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