October 2005 Newsletter

Grievances and Complaints:
Are You in Compliance with Federal Government Rules?

The Centers for Medicare and Medicaid Services (CMS) is the federal agency regulating organizations that receive money from either Medicare or Medicaid. Most hospitals fall into this category, since a high percentage of most hospital patients’ bills are paid by either Medicare or Medicaid. The CMS regulations are called “Conditions of Participation” (CoPs). Section 482.13 of the CoPs concern grievances, and how they should be handled.

An update to 482.13 was recently released by CMS, and took effect September 19, 2005. There are many changes from earlier versions. This article outlines some of the requirements of 482.13. In our experience, many hospitals are struggling with how to comply with these CoPs, and many who do not have a Patient Representative/ Advocate/Ombudsman are unaware that the requirements even exist.

CMS first released CoPs regarding grievances in 1999, and they have been challenging to hospitals, and Patient Advocates, ever since. This article summarizes key features of the latest version of the CoPs on this topic. For the complete wording of this latest version, download this .pdf document from the Society for Healthcare Consumer Advocacy. You should also be able to visit the CMS website to download a similar document, but as of this writing the latest changes do not appear on the site at this location. If you need additional information on these CoPs, we would be happy to help.

Key Features of CMS CoPs on Grievances
(and complaints)

  • The hospital's governing body is responsible for handling grievances, unless they have delegated this to a committee. The delegation must be in writing. Is this in your policies?

  • The grievance committee "is more than one person." It can be an ad hoc group composed of the Patient Representative and the manager(s) involved in the grievance. It could also be a standing committee. Is the “grievance committee” defined in your policy?
  • Hospitals must inform patients of their right to file a grievance. They must include the name, phone number, and address of the state agency (often the Department of Health) as well as the internal hospital resource. They must also inform patients of their right to file a grievance with the CMS contracted Quality Improvement Organization (QIO). Are these numbers in your Patient Rights handouts?
  • All grievances require "a written response to the patient that contains the name of the hospital contact person, the steps taken on behalf of the patient,…the results of the grievance process, and the date of completion.” Are such letters being written?
  • It is expected that a response will be sent to the patient within 7 calendar days. If resolution has not occurred, a letter outlining the process and expected time to resolution should be sent within 7 days. Is anyone in your hospital making sure this is happening?

  • Data from grievances must be used in the hospital’s Performance Improvement efforts. Is your complaint/grievance data being reviewed by appropriate hospital committees and used to plan improvements?

Definition of a Grievance

Because of the requirement that all grievances involve a written response, hospitals and Patient Representatives/Advocates/Ombudsmen were concerned about the initial definition of a grievance, which seemed to encompass all but the most minor of complaints. The newest language of the CoP has relaxed the definition somewhat.

  • "A 'patient grievance' is a written or verbal complaint (when the verbal complaint…is not resolved at the time of the complaint by staff present)…regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with a CoP, or a Medicare billing complaint related to rights…[about premature discharge, etc.]"

  • "Staff Present" includes any hospital staff present at the time of the complaint, or who can quickly be at the patient’s location (underscored words are new, less restrictive language).

  • If a verbal complaint cannot be resolved at the time of the complaint,...then it is a grievance. This includes situations where an inpatient complaint requires investigation before it can be resolved.

  • Billing issues are not usually grievances, unless they concern Medicare patients alleging their rights to refuse payment because of care and treatment issues.

  • A written complaint is always considered a grievance, except for negative comments from unidentified patients on a survey.

  • Post-hospital verbal complaints that would have been handled by staff present if they had known about the problem during the patient's stay/visit are not required to be defined as a grievance. This language is new, and significantly loosens the definition of a grievance.

  • All complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are considered to be grievances.

The CoPs concerning complaints and grievances are somewhat cumbersome and confusing, although the newest release clarifies some issues. JCAHO and Medicare inspectors in some states are paying a great deal of attention to these CoPs, so it is a good idea to become familiar with them, and be sure they are incorporated into both your policies and your actual practices. For help, feel free to contact us at awoodw3369@aol.com or 216-631-1852.



Real Life Customer Service Case

The following situation is a compilation of several stories that are fairly common occurrences. Consider using it as a case for quick discussions in staff meetings.

Anxious parents bring a toddler to an ED. The child has a fever, is crying on and off, and seems to be in obvious discomfort. Care is given, and the patient is discharged, with or without medications as seems appropriate. As part of the discharge instructions, parents may be told to bring the child back "if things get worse." Usually the parents are encouraged to follow up with the family's pediatrician. Several days later, the child's condition has worsened, and in the pediatrician's office, the diagnosis is different than it was in the ED. When the parents get a bill from the ED, they feel they should not have to pay, because of the "misdiagnosis."

  • Is this a common occurrence in your facility?
  • Over and above the question about the bill, what affect does this have on the parents' trust and loyalty to the hospital?
  • What steps can you take to "set the stage" for this situation, so that parents do not lose faith in the hospital, but see the ED staff as concerned partners in their child’s care?
  • How could you satisfy the parents without writing off the co-pay?
  • What other situations exist where a proactive intervention may prevent complaints caused by unmet expectations -- for example, the patient who is transferred from ICU to a med/surg bed and feels the med/surg nurses are not as good because they aren’t as visible.


We all grow when we learn from each other!

Let us know if you find this newsletter helpful. If you have a case study you would like us to include, or if there are certain topics you would like to see addressed, please tell us by sending an email to awoodw3369@aol.com, or by calling 216-631-1852.

About This Newsletter

This newsletter is published for clients and colleagues of A. Woodward & Associates, and for others who are interested in customer service, employee relations, and organizational communication, especially in healthcare organizations.

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